








' 






























































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MEDICAL DIAGNOSIS. 



GREENE. 






I 



THE LEATHER BOUND SERIES 

OF 

MEDICAL MANUALS 



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With 160 Illustrations. i2mo. xxx + 595 pages. Full Limp Morocco, 
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*** Otlier Volumes in Preparation. 



P. BLAKISTON'S SON & CO. 
Publishers : : PHILADELPHIA 



MEDICAL DIAGNOSIS 



A MANUAL FOR 



STUDENTS AND PRACTITIONERS 



BY 

CHARLES LYMAN GREENE, M. D. 

PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF MINNESOTA; 
ATTENDING PHYSICIAN, ST. LUKE'S HOSPITAL, THE CITY HOSPITAL AND THE ST. PAUL 
FREE DISPENSARY; MEMBER OF THE ASSOCIATION OF AMERICAN PHYSICIANS, THE 
AMERICAN MEDICAL ASSOCIATION, AMERICAN ASSOCIATION FOR THE ADVANCE- 
MENT OF SCIENCE; AUTHOR OF " THE EXAMINATION FOR LIFE INSUR- 
ANCE AND ITS ASSOCIATED CLINICAL METHODS," ETC., ETC. 



WITH 7 COLORED PLATES AND 230 ILLUSTRATIONS 



PHILADELPHIA 

P. BLAKISTON'S SON & CO. 

I O I 2 WALNUT STREET 
1907 






LIBRARY of CONGRESS 

Two OoDfeg Received 

JAN 15 190/ 

jpOMfrtfht E"try. 

r\ XXc, No 



flLASS 

U/6 



EisT 

ed I 



m 



h 



"> 



Copyright, 1907, By P. Blakiston's Son & Co. 



Printed by 

The Maple Press, 

York, Pa. 



DEDICATION 



TO MY STUDENTS, PAST AND PRESENT, 
THIS LITTLE VOLUME IS DEDICATED. 



PREFACE 



This little volume embodies the author's conception of the type of 
book most generally useful to the over-taxed student and general practitioner 
and he has tried to make it a concise, practical and thoroughly modern 
handbook of convenient size and form. 

It is not a mere compend, nor yet is it intended that it shall take the 
place of the many elaborate and valuable larger works relating to medical 
diagnosis, but it represents an effort to achieve the requisite completeness 
through direct statement, logical arrangement, and the avoidance of un- 
proven or unessential theories and obsolete, time consuming or superfluous 
methods. To the same end, marginal notes and running page headlines 
supplement the full index and the illustrations, small in size though large in 
number, are believed to possess the virtues of simplicity and teaching value. 
The author hopes that he may have in some measure succeeded in meeting 
the exacting requirements of an undertaking, the difficulties of which are in 
inverse ratio to the size of the product. 

For the kind suggestions of his confreres and especially to Drs. Haldor 
Sneve and Frank E. Burch for valuable services freely tendered in connection 
with the revision of manuscript sections dealing with the nervous system and 
the clinical .examination of the eyes, he is most grateful. No less does he 
appreciate the courtesy and patience of his publishers and the technical re- 
source which makes of 683 clearly printecf and freely illustrated pages a 
volume which in shape, size, form and binding conforms to the specific 
purpose of the book. 

Charles Lyman Green f. 
Saint Paul. November, 1906. 



CONTENTS, 



Preliminary Remarks on Case-taking and Diagnosis 



Outward Signs of Disease 3-38 

Facial expression in disease, 4; dress, 5; color of the skin, 5; jaundice, 8; dry 
and moist skin, 10; edema, 10; ascites, 12; subcutaneous emphysema, 14; 
subcutaneous hemorrhages, 14; collateral venous circulation, 14; drug erup- 
tions, 15; desquamations, 15; scars, 15; head, 16; eyelids, 17; eyes, 17; nose, 
19; ear, 19; lips, 20; breath, 20; buccal cavity, 20; stomatitis, 21; gums, 23; 
teeth, 24; jaws, 25; palate, 25; hands, 25; arm and leg, 26; back, 27; joints, 
27; voice and speech, 28; aphasia, 29; tremor, 30; spasms, cramps and con- 
vulsive seizures, 31; station, attitude and gait, 33; decubitus, ^; gait, 35; 
weight and height, 36. 

Age, Sex, Habits, Social State and Residence in Disease 38-49 

Age, 38; sex, 39; race, 39; habits and environment, 39; drug habit, 40; mar- 
ried or single, 41; occupation, 41; habits in relation to occupation, 42; occu- 
pations involving mental strain, 42; occupations involving use of mineral 
poisons, 43; occupations involving excessive heat, 44; occupation stigmata, 44; 
residence, 45; family history, 46; alternatives in heredity, 46; heredity, 47; 
previous illness, 49; misnamed ailments, 49. 

History of " Present Ailment " and Analysis of Certain Common- 
Symptoms 40-80 

History of present ailment, 49; fever, 49; temperature range in the human 
body, 50; pathologic variations in temperature, 51; febrile types, 52; diag- 
nostic import of fever, 52; phenomena of fever, 54; pulse and respiration, 55; 
exanthems, 55; coma, 57; stupor and lethargy, 58; pain, 61; character and 
seat of pain, 61; colic, 62; abdominal pain, varieties and causes, 64; head- 
ache, 66; neuralgia, 68; neuritis, 71; muscular rheumatism. 71; tenderness. 
73; perversions of sensation, 73; insomnia, 75; vertigo, 75; dyspnoea, 76; 
orthopeona, 78; variations in respiratory rhythm, 7S; hiccough. 70: shock and 
collapse, 79; concealed hemorrhage, So. 

Diseases of the Thoracic Viscera 8 

Topographical anatomy of the chest. So; regional divisions, 80; thoracic 

viscera, Si; lungs, Si; Traube's semilunar space, Sj; lobes of lungs. 8a j 

ix 



I 



CONTENTS. 



heart, 83; aorta, 83; mobility of heart, 83; heart dulness, 83; apex beat, 84; 
valves, 84; methods employed in diagnosis of pulmonary and cardiac dis- 
ease, 84; preparation of patient, 85; attitude of patient and physician, 85; 
examination of chest with special reference to lungs and pleura, 85; general 
form of chest, 86; general deformities of chest, 86; localized changes in out- 
line, 87; chest measurements, 88; chest movements, 88; Litten's diaphragm 
phenomenon, 88; fluoroscopic methods, 89; palpation of chest, 89; respira- 
tory movements, 89; vocal fremitus, 90; pressure palpation, 91; percussion 
of chest, 91; auscultatory percussion, 92; percussion sounds, 93; normal 
notes, 93; lung borders, 95; percussion of chest in disease, 96; special modi- 
fications of the percussion note, 97; auscultation of the chest, 98; basis of 
auscultatory phenomena, 98; technic of auscultation, 99; attitude of patient, 
100; pulmonary area demanding special attention, 100; variations in bre th 
sounds, 101; rales, 104; post-tussive suction, 106; metallic tinkling, 106; 
Hippocratic succussion, 106; friction sounds, 106; X-ray examination of the 
chest, 106; fluoroscopic signs and their significance, 109; cough, 109; sputum, 
contents, varieties, and examination, in. 

Diseases of the Nose, Pharynx, and Larynx n 5-1 23 

Technic of examination, 115; acute coryza, 116; chronic rhinitis, 116; hy- 
pertrophic rhinitis, 116; exostoses and enchondroses, 117; septal deviations, 
117; septal haematoma, 117; septal abscess, 117; atrophic rhinitis, 117; 
necrosing ethmoiditis, 117; hay-fever, 118; nasal polypi, 118; sarcoma and 
carcinoma, 118; nasal syphilis, 118; epistaxis, 118; foreign bodies in the 
nose, 119; pharyngitis, acute, chronic, and atrophic, 119; post-nasal aden- 
oids, 119; syphilitic pharyngitis, 120; retro-pharyngeal abscess, 120; paral- 
ysis and tumors of pharynx, 121; acute tonsillitis, 121; suppurative tonsillitis, 
121; chronic tonsillitis, 121; simple, acute, and subacute laryngitis, 121; 
chronic laryngitis, 122; edema of the glottis, 122; croup, 122; true croup, 
123; syphilitic laryngitis, 123; tuberculous laryngitis, 123; tumors of the 
larynx, 123. 

Diseases of the Bronchi, Lungs and Pleura 123-167 

Acute and chronic bronchitis, 123; fibrinous bronchitis, 125; diseases asso- 
ciated with chronic bronchitis, 125; emphysema, 125; foreign bodies in the 
bronchi, 127; bronchiectasis, 127; spasmodic asthma, 128; pleurisy, 131; 
rhythmic lateral displacement of heart, 134; empyema, 135; pleuritic adhe- 
sions, 135; interlobular pleurisy, 136; chronic pleurisy, 136; pneumothorax, 
136; hydrothorax, 138; lobar pneumonia, 138; broncho-pneumonia, 144; 
atelectasis, 148; congestion of the lungs, 149; tuberculosis, 151; acute miliar}' 
tuberculosis, 153; acute pneumonic phthisis, 154; chronic ulcerative tuber- 
culosis, 155; pulmonary infarct, 161; pulmonary abscess, 161; pulmonary 
gangrene, 162; pulmonary tumors, 162; diseases of the bronchial glands, 162; 



CONTENTS. XI 



mediastinal abscess, 164; chronic interstitial pneumonia, 164; pulmonary 
syphilis, 165; pulmonary actinomycosis, 166; aspergillomycosis, 166; pulmon- 
ary hydatids, 166; chylous pleurisy, 166; malignant growths of the pleura, 
166. 

Diseases of the Heart and Blood-vessels 167-223 

Arterial pulse, 167; pulse frequency, 168; tachycardia, 169; bradycardia, 
169; irregularity and intermittency, 170; arrhythmia, 170; varieties of pulse, 
171; determination of blood-pressure, 172; sphygmograph, 173; sphygmo- 
gram, 174; normal and abnormal tracings, 175; venous pulse, 176; diastolic 
venous collapse, 176; positive penetrating venous pulse, 177; visible respira- 
tory venous phenomena, 177; examination oj the heart and great blood-vessels, 
177; apex beat, 177; displacement of apex beat, 178; systolic retraction, 178; 
precordial pulsations, 178; pulsation in region of manubrium, 178; precord- 
ial bulging, 179; palpation of precordium, 179; percussion of precordium, 
179; auscultation of precordium, 180; heart sounds, 181 ; reduplication of heart 
sounds, 182 ; heart murmurs, 183 ; hemic murmurs, 184; pleuro-pericardial mur- 
murs, 185; accidental murmurs, 185; organic heart murmurs, 186; rhythm of 
organic murmur, 189; relative frequency of murmurs, 190; hypertrophy and 
dilatation, 191 ; mitral regurgitation, 191 ; aortic stenosis, 192 ; tricuspid regurgi- 
tation, 193; pulmonary stenosis, 193; mitral stenosis, 194; aortic regurgitation, 
195; tricuspid stenosis, 197; pulmonary regurgitation, 198; congenital heart 
disease, 198; persistent ductus arteriosus, 199; persistent aortic isthmus, 199; 
compensation and incompensation, 199; impaired compensation, 200; com- 
plete incompensation, 202; relative insufficiencies, 202; thoracic aneurism, 
204; X-ray in diagnosis of aneurism, 204; symptoms of aneurism, 205; 
aneurism of first portion of arch, 208; aneurism of transverse portion of arch, 
209; differential diagnosis of aneurism, 210; endocarditis, 213; subacute en- 
docarditis, 214; ulcerative endocarditis, 214; chronic endocarditis, 215; peri- 
carditis, 215; chronic adhesive pericarditis, 216; myocarditis, 217; acute myo- 
carditis, 218; chronic myocarditis, 218; rupture of the heart, 220; aneurism 
of the heart, 220; foreign bodies in the heart, 220; new growth of the heart, 
220; situs viscerum inversus, 221; arterio-sclerosis, 221; angina pectoris, 222. 

Diseases of the Abdominal Organs 223-376 

Topography and regional divisions, 224; technic of abdominal examinations, 
226; physical examination of abdomen and its special application, 227; visi- 
ble peristalsis, 228; liver, 228; gall-bladder, 229; spleen, 230; kidneys, 231; 
stomach, 233; physical examination of the stomach, 233; stomach tube and 
its uses, 236; technic of introduction of stomach tube, 237; examination of 
gastric contents, 237; test-meals, 23S; qualitative tests for gastric contents, 
239; test for motor power of stomach, 241; quantitative tests for gastric 
contents, 241; end reactions, 243; hyperchlorhydria, 245; chronic hyperse- 
cretion, 246; hypochlorhydria, 246; anachlorhvdria, 246; hetcrochvlia, _v j 7 ; 



^ 



CONTENTS. 



gastric neuroses, 247; anorexia, 247; bulimia, 247; nausea and vomiting, 
248; the vomitus, 249; heartburn, 252; peristaltic unrest, 252; eructation, 
252; gastric spasm, 252; gastric hyperaesthaesia, 253; gastralgia, 253; nervous 
dyspepsia, 253; anorexia nervosa, 254; achylia gastrica simplex, 254; gastric 
atrophy, 254; disordered motility, 255; gastric atony, 255; gastroptosis, 256; 
chronic dilatation, 257; acute atony, 258; post-stenotic motor insufficiency, 
258; hour-glass contraction, 260; acute gastritis, 261; chronic gastric 
catarrh, 261; gastric ulcer, 262; duodenal ulcer, 267; ulcer with adhesions, 
268; gastric erosions, 268; carcinoma, 269; gastric crises, 272; arterio- 
sclerotic abdominal crises, 272; syphilis of the stomach, 273; tuberculosis of 
the stomach, 273; congenital stenosis of the stomach, 273; diseases of the 
intestines, 274; the feces, 274; microscopic examinations, 275; test diet, 276; 
concretions, 277; haemorrhoids, 278; enteritis, 279; acute intestinal indiges- 
tion, 279; acute fermentative diarrhoea, 280; chronic enteritis, 280; cholera 
infantum, 280; dysentery, 280; membranous enteritis. 283; miscellaneous 
intestinal neuroses, 283; chronic intestinal obstruction, 284; chronic intus- 
susception, 285; constipation, 285; fecal accumulation, 286; duodenal ulcer, 
286; thrombosis and embolism, 287; tuberculosis of the intestines, 287; 
syphilis of the intestines, 287; enteroptosis, 287; appendicitis, 288; chronic 
appendicitis, 291; acute peritonitis, 291; localized peritonitis, 292; chronic 
peritonitis, 293; proliferative peritonitis, 294; tuberculous peritonitis, 294; 
cancer, 295; diseases of the pancreas, 295; acute hemorrhagic pancreatitis, 
295; acute suppurative pancreatitis, 296; gangrenous pancreatitis, 296; 
chronic pancreatitis, 296; pancreatic cysts, 296; carcinoma, 296; calculi, 
296; diseases of the liver and biliary passages, 296; congenital anomalies, 
296; inflammation of the liver, 297; pyaemic abscess of the liver, 297; hepa- 
tic hyperemia, 299; tumors of the liver, 299; echinococcus cysts, 300; cir- 
rhosis of the liver, 301; catarrhal jaundice, 305; acute cholecystitis, 305 ; 
cholelithiasis, 305; acute yellow atrophy, 308; Weil's disease, 308; diseases 
of the esophagus, 309; acute esophagitis, 309; strictures and diverticula, 309; 
carcinoma, 310; spasm, 310; urinalysis and diseases of the kidneys, 310; 
urinary examination, 311; polyuria, 312; oliguria, 312; frequency of mic- 
turition and dysuria, 312; changes in urine, 313; specific gravity, 315; 
urinary solids, 316; urea, 320; albuminuria, 324; tests for albumin, 327; 
pus, 331; blood, 331; bile, 2>2>2>'^ tests f° r glucose, ^^; acetone, diacetic 
acid, and oxybutyric acid, 338; examination of urinary sediments, 339; casts, 
344; bacilli in urine, 348; gonococcus, 249; Ehrlich's diazo-reaction, 349; 
uraemia, 350; cryoscopy, 352; cryoscope, 353; renal inefficiency, 354; 
chronic passive congestion of the kidney, 355; acute congestion of the kid- 
ney and acute nephritis, 356; chronic parenchymatous nephritis, 359; small 
white kidney, 361; chronic interstitial nephritis, 361; chronic diffuse 
nephritis with exudation, 364; amyloid kidney, 365; movable and floating 
kidney, 365; pyelitis and pyelonephritis, 367; renal tuberculosis, 368; hy- 
dronephrosis, 369; acute cystitis, 369; chronic cystitis, 369; tuberculosis of 



CONTENTS. Xlll 



the bladder, 370; tumors of the bladder, 370; acute prostatitis, 370; chronic 
prostatitis, 370; urinary calculus, 371; chemic examination, 371; glycosuria, 
372; diabetes mellitus, 373; diabetes insipidus, 376. 

Diseases Dependent upon or Associated with Changes in the Blood and 

Ductless Glands 376-427 

Examination of the blood, 376; hematology, 376; clinical tests, 377; terms, 
376; color index, 378; obtaining blood for examination, 378; preparation of 
slides and cover-glasses, 378; making a smear, 379; fixing, 379; examination 
of fresh blood, 379; staining preparations, 380; haemoglobin, 381; tests for 
haemoglobin, 382; hsemoglobinometers, 382; Tallgvist's, 382; Dare's, 383; von 
Fleischl's, 383; Oliver's, 385; Gower's, 385; Sahli's, 385; Hammerschlag's 
method, 385; erythrocytes and leukocytes, 385; red blood cell characteristics, 
385; classification of leukocytes, 386; abnormal forms, 386; abnormal eryth- 
rocytic forms, 387; unusual erythrocytic staining reactions, 387; nucleated 
red cells, 387; blood cell count, 388; leukocyte count, 390; Oliver's haemo- 
cytometer, 391; the haematocrit, 391; leukocytosis and lymphocytosis, 392; 
leukocytosis of diseases, 393; leukopaenia, 393; lymphocytosis, 394; eosino- 
philia, 394; melanaemia, 394; iodophilia, 394; perinuclear basophilia, 395; 
agglutination reaction (Widal), 395; counting of blood plates, 396; coagula- 
tion time, 396; alkalinity, 396; cytodiagnosis, 396; inoscopy, 397; diseases 
of the blood, 398; anaemias, 398; symptoms, 398; causes, 401 ; chlorosis, 402; 
secondary anaemia, 402; pernicious anaemia, 403; splenic anaemia, 404; leu- 
kaemia, 404; splenomedullary leukaemia, 404; lymphatic leukaemia, 406; poly- 
cythemia, 407; Osier's disease, 408; Hodgkin's disease, 408; acute Hodg- 
kin's disease, 409; purpura, 410; purpura haemorrhagica, 412; haemophilia, 
412; scorbutus, 413; Addison's disease, 414; lymphatism, 416; myxcedema, 
416; cretinism, 417; myxcedema in adults, 418; exophthalmic goitre, 419; 
acromegaly, 421; osteitis deformans, 424; leontiasis ossea, 424; micromegaly, 
424; pulmonary hypertrophic osteoarthropathy, 424; rickets, 424; infantilism, 
426; obesity, 426. 

Infectious Diseases 427-488 

Typhoid fever, 427; influenza, 438; Asiatic cholera, 441; bubonic plague, 
443; yellow fever, 446; malaria, 448; relapsing fever, 452; typhus fever, 
453; malta fever, 454; milk fever, 456; mountain fever, 456; miliary fever; 
foot and mouth disease, 456; flood fever, 456; kala-azar, 457; measles, 457; 
mumps, 459; scarlet fever, 400; rotheln, 462; diphtheria, 462; smallpox, 466; 
vaccination, 470; varicella, 473; whooping cough, 173; syphilis, 475; hered- 
itary syphilis, 480; syphilis hereditaria tarda, 480J erysipelas, 48 1 ; pyaemia 

and septicaemia, 481; leprosy, 482J anthrax, 483; malignant pustule, 484; 

malignant anthrax edema, |S|; internal anthrax, 484; hydrophobia. 485; 
tetanus, 4S6; glanders, 4S7; actinomycosis, 487. 



XIV CONTENTS. 



Intoxications 488-494 

Sunstroke, 488; heat exhaustion, 489; alcoholism, 489; chronic alcoholism, 
489; delirium tremens, 490; morphine and cocaine habits, 490; chronic lead 
poisoning, 490; chronic arsenical poisoning, 492; ptomaine poisoning and 
food poisoning, 492; ergotism, 492; pellagra, 493; lupinosis, 493: meat 
poisoning, 493; lacquer poisoning, 494. 

Parasitic Diseases 494-507 

Rhizopoda, 494; flagellata, 494; trematoda, 494; cestodes, 496; tapeworms, 
496; taenia saginata, 496; taenia solium, 497; bothriocephalus latus, 497; 
davainea madagascariensis, 498; taenia echinococcus, 498; ascaris lumbric- 
oides, 500; oxyuris vermicularis, 500; trichiniasis, 501; uncinariasis, 501; 
filariasis, 502; dractontiasis, 504; tricocephalus dispar, 504; dicotophyme 
gigas, 504; strongyloides intestinalis, 504; psorospermiasis, 504; trypan- 
osome fever and sleeping-sickness, 505; pyroplasmosis hominis, 505; sar- 
coptes scabiei, 506; pediculus capitis, 506; pediculus corporis, 506; pedic- 
ulus pubis, 507; vagabond's disease, 507; cemex lectularius, 507. 

Rheumatic Affections 507-512 

Acute rheumatism, 507; infectious arthitis, 508; tuberculous arthritis, 509; 
hip-joint disease, 509; subacute rheumatism, 509; gout, 509; irregular gout, 
510; arthritis deformans, 510; chronic progressive arthritis deformans, 511. 

The Nervous System and its Diseases 512-622 

Structure, 512; mode of action, 512; conductor in motor and sensory areas, 
512; reflexes, 513; motor tracts, 514; direct sensory tract, 517; indirect sen- 
sory tract, 518; functions of sensory tracts, 519; functions of the tracts of 
the spinal cord, 519; tract involvement in disease, 522; terms in common 
use, 522; etiologic factors, 522; degeneration, 523; classification, 525; 
sequence of degenerative changes, 525; relation of pathologic changes to 
symptomatology, 525; sensory centers and pathways, 525; girdle sensations, 
526; motor lesions, 526; unilateral spinal cord lesions, 526; complete trans- 
verse spinal cord lesions, 527; the reflexes, 527; examination of the muscles, 
531; certain psychic and sensory derangements, 534; investigations of sen- 
sory functions, 537; topical diagnosis, 539; cortex, 539; silent areas, 539; 
centrum semiovale, 541; optic thalamus, 541; internal capsule, 541; crura, 
542; corpora quadrigemina, 542; pons, 542; medulla oblongata, 543; cere- 
bellum, 543; segmental paralyses, 543; brachial plexus paralysis, 549; certain 
spinal nerves, 549; cranial nerves, 551; olfactory nerve, 551; optic nerve, 
eye, and eye reflexes, 552; eye reflexes, 553; optic nerve, 554; ophthalmos- 
copy, 557; retinoscopy, 558; motor nerves of the eye, 560; tests for lesions 
of the 3rd, 4th, 6th nerves, 561; trifacial nerve, 562; sixth nerve, 563; 
seventh nerve, 563; facial spasm and paralysis, 564; auditory nerve, 564; 
deafness, 565; Meniere's disease, 565; glosso -pharyngeal nerve, 566; the 



CONTENTS. xv 

vagus, 566; spinal accessory nerve, 567; hypoglossal nerve, 568; sympa- 
thetic nervous system, 568; diseases 0} the brain and spinal cord, 568; hemor- 
rhagic pachymeningitis, 568; external pachymeningitis, 569; extra-meningeal 
hemorrhage, 569; caisson disease, 570; miliary sclerosis, 570; multiple 
sclerosis, 570; cerebral congestion 571; cerebral anaemia, 571; cerebral 
edema, 571; thrombosis of the cerebral veins and sinuses, 571; meningitis, 
571; types, 573; epidemic cerebro-spinal meningitis, 573; acute tuberculous 
meningitis, 576; syphilitic meningitis, 576; alcoholic meningitis, 577; sec- 
ondary and septic meningitis, 577; infantile meningitis, 577; chronic menin- 
gitis, 578; congenital hydrocephalus, 578; hydrocephalus in adults, 578; 
tumors of the brain, 578; general factors in relation to tumor identification, 
579; cerebral hemorrhage, embolism, and thrombosis, 581; cerebral abscess, 
586; paralytic dementia, 587; anaemia of the cord, 589; thrombosis, embo- 
lism, endarteritis of the cord, 590; locomotor ataxia, 590; ataxic paraplegia, 
592; primary combined sclerosis, 592; hereditary ataxia, 592; cerebellar 
hereditary ataxia, 593; primary lateral sclerosis, 593; hereditary spastic 
spinal paralysis, 594; spastic paralysis of infants, 594; hysteric spastic para- 
plegia, 595; amaurotic family idiocy, 595; syringomyelia, 595; compression 
myelitis, 596; acute transverse myelitis, 596; primary chronic myelitis, 598; 
Landry's paralysis, 599; poliomyelitic anterior acuta, 599; progressive 
muscular atrophy, 600; amyotrophic lateral sclerosis, 601; muscular dvs- 
trophies, 602; pseudo-muscular hypertrophy, 602; diseases of the muscles 
604; myotonia, 604; myasthenia gravis, 604; myositis, 604; myositis ossif- 
icans progressive, 604; paramyoclonus multiplex, 605; neuritis, 605; acute 
febrile polyneuritis, 605; toxic neuritis, 606; beri beri, 606; recurrent mul- 
tiple neuritis, 606; pressure paralysis, 607; von Recklinghausen's disease, 
607; neuralgia, 607; herpes zoster, 607; periodic transient paralysis, 607; 
Raynaud's disease ; 608; erythromelalgia, 609; acroparesthesia, 609; inter- 
mittent joint effusions, 609; angioneurotic edema, 609; facial hemiatrophy, 
609; epilepsy, 610; chorea, 612; convulsive tic, 614; impulsive tic, 614; 
pandemic chorea, 614; saltatory spasm, 615; paralysis agitans, 615; hysteria, 
615; neurasthenia, 618; traumatic neurasthenia and hysteria, 620. 

Malingering 622-0 — 

Simulated injury, 623; commoner feigned states, 624; anaemia, 624; angina 
pectoris, 624; aphonia, 624, asthma, 624; atrophy of the extremities. 6245 
blindness, 624; cancer, 624; catalepsy, 626; cerebral concussion, 626; 
chorea, 626; consumption, 626; contractures, 626; convulsions, 627; cutan- 
eous lesions, 627; diarrhoea and dysentery, 027; dropsy, edema, and ascites, 
627; dyspepsia, 627; calculi, 62$; epilepsy, 6a8j eye diseases, 6a8j feigned 
sleep, 628; fever, 628; fictitious wounds, 6a8j fractures, 629; headache. 629; 
hemorrhages, 629; hernia, 630; hydrocele, (130; hydrocephalus, 630; hydro- 
phobia, 630; incontinence of mine, 63OJ insanity. 63OJ jaundice. 031; joints, 
631; limping, 631; lumbago, 631; ozena, 63 1 J pain and tenderness. 031; 



CONTENTS. 






paralysis, 632; peritonitis, 632; rheumatism, 632; retention of urine, 632; 
sciatica, 632; scoliosis, 633; scurvy, 633; unconsciousness, 633; venereal 
diseases, 633; vertigo, 633; vomiting, 633; wry neck, 633; conditions simu- 
lating death, 634; asphyxia, 634; catalepsy, 634; syncope, 634; signs of life 
in one apparently dead, 634. 

Summary of Symptoms and Treatment or Acute Poisoning 635-641 

Mineral acids, 635; aconite, 635; arsenic, 636; atropin, 636; cantharides, 
636; carbolic acid, 637; caustic alkalies, 637; chloral hydrate, 637; cocaine, 
637; colchicum, 637; croton oil, 637; castor oil, 638; corrosive sublimate, 
638; formaldehyde, 638; gelsemium, 638; hydrocyanic acid, 638; lead 
acetate, 639; lobelia, 639; mushroom poisoning, 639; oxalic acid, 639; 
opium, 639; phosphorous, 640; potassium nitrate, 640; potassium chlorate, 
640; stramonium and hyoscyamus, 640; strychnine, 640; tartar emetic, 641; 
tartaric acid, 641. 

Table of Approximate Metric Equivalents 642 

Centigrade and Fahrenheit Scales 643 



MEDICAL DIAGNOSIS, 



Its scope. 



PRELIMINARY REMARKS ON CASE-TAKING AND DIAG- 
NOSIS. — A diagnosis means more than giving a name to a disease, and 
must include a correct estimate of the constitutional peculiarities of the 
patient, the nature and extent of pathologic changes, the effect of age, 
occupation, residence, habits, heredity, past ailments, and even the per- 
sonal characteristics of the individual. Accurate diagnosis and intelli- 
gent prognosis are prerequisite to effective treatment. 

From his text-books and the lecture room, the student learns the 
known types; at the bedside he soon realizes that variation from the 
type, and the personal equation must be carefully studied. Diagnosis 
in medicine, even more than in surgery, must be based upon a sufficiency 
of facts, truthfully recorded, intelligently sifted, and viewed without 
bias or preconception. Self-deception spells failure, as does that narrowed 
mental vision, which cannot see and appreciate new facts of later develop- 
ment, or the cowardice that fears to give up an erroneous preconcep- 
tion. Our knowledge of clinical symptoms in a given case depends 
either upon (a) what we are told or (b) what we see or determine for our- 
selves, i.e. they are either (a) subjective or (b) objective, the latter group 
including bacteriologic and chemic tests as well as physical signs. For 
the former, we depend upon the patient, and often encounter garrulity, 
stupidity, concealment, deceit or hypochondriacal exaggeration. If 
the patient is comatose or possesses no common language, we have 
no testimony save that of outsiders, and in any event must exercise evidenc 
sound judgment, keen discrimination and a certain facility in cross 
examination or we cannot give to these fallible yet valuable subjective 
data their proper weight. 

To make a case history full, accurate, yet concise, to elicit the salient 
fads and assign to each its proper value and perspective demands 
that the observer be full of knowledge, quick of perception and capable 
of avoiding both the shoals of omission and the rocks of verbosity. 
Certain routine inquiries should always be made, ami the student 
should be extremely careful and painstaking in the days of his appren- 

i 



Text book 

vs. 
Bedside. 



The open 
mind. 



Subjective 

vs. 
Objective. 



Hearsay 



r > r o 

vs. 

Expert. 



MEDICAL DIAGNOSIS. 



" Snap " 
diagnosis. 



Direct 

vs. 
Indirect 
methods. 



Thera- 
peutic 
diagnosis. 



Quack 

vs. 
Physician. 



Consulta- 
tion. 



ticeship, though the skilled clinician can seize upon the cardinal points 
of his case and arrive at correct conclusions in a comparatively short 
time and with a minimum waste of words and ink. Certain single 
symptoms may name the disease, and such are termed pathognomonic, 
but woe to the man who is betrayed into the habit of making "snap" 
diagnosis. His opportunity passed when pathology came to her 
estate. Diagnosis by exclusion is a useful though roundabout and 
often unsatisfactory method of arriving at conclusions by a process 
of negation, the object being to find in the signs or symptoms pre- 
sented by a given case, one or more inconsistent with the diagnostic 
symptom group of all diseases save one. Modern advance has greatly 
reduced the value of, and necessity for the method. Typhoid need no 
longer be laboriously established by negation, but in almost every case 
may be directly and promptly diagnosed by the Widal test and diazo- 
reaction. Its simulator, malaria, is no less positively known by the 
Plasmodium as revealed by a blood examination. In some instances 
a therapeutic diagnosis is necessary, as for example, in dealing with an 
obscure or ancient suspected syphilitic infection when mercury and the 
iodides may banish all doubt. Many students and some practitioners 
habitually diagnose medical curiosities and such should remember that 
the doctrine of probabilities is against them, and thoroughly thresh out 
the variations of the prosaic and simple before assuming the long odds. 
On the other hand it falls to the lot of every man to encounter rarities 
and their recognition means added credit and reputation. The quack 
never hesitates to make a diagnosis, but the physician of parts, knowledge, 
and honesty must often make none or at best a provisional one, and 
wait for more light. The quack never acknowledges an error; the 
honest man whatever his ability must occasionally confess one. The 
more ignorant and dishonest the man, the more dogmatic and rapid 
his diagnoses, for with breadth and depth of knowledge comes its highest 
gift, a conception of its limitations. The physician must work method- 
ically, deliberately, and with open mind, but once his opinion is formed, 
it should find emphatic expression, and every subsequent order and 
act be characterized by firmness and decision. If to these qualities 
he adds that modest self-confidence, born of fulness of knowledge and 
resource, his are the keys of the temple of fame. Such a man can and 
will deal with intelligent patients frankly and freely, he will not be afraid 
to call counsel, and need not feel that his after-conference with his 
consultant must be held in private according to a prevailing custom, 
more honored in the breach than in the observance. There are few 



THE OUTWARD SIGNS OF DISEASE. 



The poll 
parrot 

method. 



families of the intelligent sort in which the physician cannot find a Lay 
confidant whom he can admit to his conferences, talk with freely and c 
honestly, and thereby increase his usefulness and gain added support 
and a valuable co-operation. So also there are few physicians who will 
use a visit of courtesy as a means of self aggrandizement, or the humilia- 
tion of a fellow practitioner, and one who cannot deal fairly with all 
parties concerned is out of place in this day and generation. Doubts, 
fears and argument, however, are not for the sickroom, where a con- 
fident bearing and cheery countenance mean oftentimes more than a 
whole pharmacopcea. 

Let the student beware of that method of study which leads him to 
arbitrarily commit to memory a long train of symptoms, without proper 
consideration of their general bearing, causes, or special and peculiar 
relations, rather let him learn to associate with each disease that which 
is peculiar and specific. A multitude of diseases, for example, are 
febrile but fevers are much alike as regards their general symptomology. 
This last he should learn thoroughly as of broad application, but stamp 
especially upon his memory the peculiar type of fever or definite varia- 
tions that any given disease presents. Furthermore, every student 
should try to get a clear mental photograph of any ailment he is studying, 
and of the pathologic changes that underlie and explain its symptoms. 
In his mind's eye he should see the man with typhoid, the chart, the 
physiognomy, attitude, rose spots, and more than that the intestinal 
ulcers that underlie them. Such a method makes for thoroughness 
and for quickness of perception and inference and no man can take an 
intelligent, comprehensive and concise case history who has not mas- 
tered these principles. 

Finally, and most emphatically, should it be stated that case-taking, 
recording and reporting should be carried into every man's practice. 
Old case books well kept are mines of knowledge and the science of 
medicine would be greatly enriched were the workers in city and hamlet 
alike to give to it reports of the unusual cases now for the most part 
allowed to pass without record.* 

THE OUTWARD SIGNS OF DISEASE. 

Every diagnosis commences with our introduction to the patient ' 

111111 ... impres- 

and even the handshake may convey mtormation ol value. The physician S1 ° n - 

*For a fuller discussion of this topic the render is referred to the delight- 
ful book of Byrom BramweU entitled "Practical Medicine and Medical 

Diagnosis." 



Mental 
photogra- 
phy. 



The value 
of the case 
book. 



J 



MEDICAL DIAGNOSIS 



Go slowly, 



Diathesis. 



should train his observation and would do well to emulate the example of 
his predecessors of a darker medical era, who were adepts by force of ne- 
cessity. On the other hand, he should avoid hasty physiognomic diagnoses, 
for appearances are often misleading. Diagnosis in disease of the nose, 
throat, eye, ear and skin is essentially that of inspection, and throughout 
the whole range of medicine and surgery it plays an important part. 

FACIAL EXPRESSION.— Character and temperament, bad habits, 
diseases past and present, may stand revealed at a glance. Tempera- 
ment is closely related to diathesis, but the latter implies a tendency 
to some special type of disease. The former has lost the prominent 
place it held in earlier times, and one need give little thought to its 
elaborate classification, though the "nervous, " " bilious, " "phlegmatic," 
"lymphatic," and "melancholic" types are often clearly defined and 
aid in diagnosis and prognosis alike. Who for example, has not encount- 
ered the "lymphatic" individual with a tuberculosis, which burns him 
to cinders, while the physician stands helpless to stay or cure? The 
expression helps us with malingerers, those forgers of symptoms who 
seek shelter under the hospital roof or wish to saddle damages for some 
spurious hurt upon the rich individual or corporation. In the hang 
dog carriage and shifting eye of the youth, and his moist clammy hand 
we may read the story of sexual abuse. If melancholy has marked 
the patient for her own, he carries on his face the impress of her signet. 
Incipient insanity of other types may manifest itself in a peculiar expres- 
sion of the eyes, "intensification of emotional expression," as it has been 
called, and a deceptively merry expression it often is. 

General Paresis in its early stages often gives outward evidence. 
Lips, tongue, fingers and facial muscles are tremulous; the pupils are 
unequal and react to accommodation but not to light. The speech 
is slow, hesitant or explosive, consonantal words are difficult for the 
victim, and his delusions of grandeur are likely to find an outlet in his 
conversation. Everything of his is superlatively beautiful, simple or 
great, and he incomparable. 

Carcinoma of the Stomach is frequently associated with a curi- 
ously morose or saturnine expression well shown in the famous statue of 
Napoleon in his last days.* This, together with marked emaciation 
and a peculiar earthy color are most suggestive. 

Syphilis. — The snuffling cry, weazened monkeyish face, fissured 
lips and raw nostrils and buttocks of a syphilitic babe are pathognomonic. 
The permanent upper central incisors of the older children are likely 

* In the Corcoran Gallery, Washington. 



Malinger- 
ers. 



The " haru 
dog " air. 



Melancho- 
lia. 



Facies and 
speech. 



Facies. 



Congenital 
syphilis. 



THE OUTWARD SIGNS OF DISEASE. 




Fig. i. — Syphilis. Grey areas 
of past alopecia. Saddle-nose. 
Patient and his father both 
showed perforated palate. 



to be peg-shaped, notched at their cutting edges, irregular and separated. 
Fine linear scars may radiate from the angles of the mouth. Keratitis 
and chronic otitis media often co-exist, and at any age a frog face (see 
illustration) may result from necrosis of the nasal arch. Syphilitic 
alopecia may be present, or have left its mark in a patchy grayness. 

Many cases of past syphilitic infection give 
no evidence that can be detected in the 
ordinary examination, the examiner being 
forced to rely upon the patient's statement 
in reply to a direct question which should 
be definitely and clearly put in the case of 
the men though manifestly impossible 
when dealing with women. One of the 
most easily recognized and pathognomonic 
syphilitic types is that combining alopecia 
or scattered areas of gray hair with saddle 
nose and perforated palate. A deeply 
fissured tongue suggests this disease and many cases of course present 
themselves with an active and unmistakable eruption or "the primary 
lesion."* 

DRESS. — The quality of the clothing and its condition may suggest 
the position in life of its wearer as well as his occupation. Carelessly 
worn and disarranged garments, stained by food droppings may suggest 
mental change, particularly if noted in a person formerly neat and well 
and carefully dressed. An ammoniacal odor suggests incontinence or 
cystitis, and white stains upon the shoes may give a hint of an existing 
saccharine diabetes. In patients formerly stout who have recently 
lost greatly in weight the old clothes may be worn and be suggestively 
loose. On the other hand the development of an anasarca may make 
the patient appear to be bursting through his clothing. Edema of 
the legs is frequently suggested by loose lacing of the shoes, which may 
be cut and slashed for the same reason or the better to accommodate 
corns, bunions or gouty toes. In the various forms of pathologic gait 
the wearing away of the shoe in a particular part may be suggestive, 
this being particularly noticeable in the spastic conditions. 

THE COLOR OF THE SKIN.— The two conditions chiefly to be 
noted are pallor and cyanosis; the pale face may or may not mean true anae- 
mia, and a high color may co-exist with a low hemoglobin percentage. 
More stress may be laid upon the color of the mucous membranes ami 

*Sec syphilis, pp. 475 to 481. 



" Frog 

face." 



Syphilis in 
adults. 



Perforated 
palate. 



Suggesting 

Drain 

trouble. 

Urinary 

Disorders. 



Recent 

weight loss 



Edema: 



Paralysis. 



aomeumes 
misleading. 



. 



f 



MEDICAL DIAGNOSIS. 



" Rosy 
chlorotics. 



Ansemic 
types. 



Nephritis. 



" Fawn 
color." 



Cardiac 
disease. 



Deceptive 
pallor. 



False 
" color." 



Underly- 
ing causes. 



though certain degrees of pallor may exist there without anaemia even 
"rosy chlorotics" usually show a pale conjunctiva. Ordinarily, one may 
regard pallor of the cheeks, lips, tongue, throat, ears, conjunctive? and 
finger nails as indicating a reduced hemoglobin percentage. The color 
varies markedly in different types of anaemia, being greenish yellow 
or almost waxy white in chlorosis or simple anaemia, a peculiar lemon 
yellow in pernicious anaemia, and a curious earthy tint in the profound 
secondary anaemia of malignant disease of the stomach. 

In Acute Bright's Disease the skin is white and an associated 
edema produces the peculiar and characteristic pasty pallor. In paren- 
chymatous nephritis we meet with pallor or in its late stages a sallow or 
brownish hue. Most authors speak of the peculiar "fawn colored" skin 
as related to interstitial nephritis, but in the author's experience it is more 
often met with in cases which come under the "mixed" type of chronic 
kidney disease, or only in the late stages of the interstitial form, the 
earlier period being often associated with the ruddy or high colored 
("clubman") countenance, and many of its victims appearing exuber- 
antly healthy. 

The color in certain forms of heart disease is both interesting and 
important. Aortic regurgitation is usually associated with a pallor of 
the indoor worker type, there being rarely any marked true anaemia, 
but even in compensated regurgitant and obstructive disease of the 
mitral valve the color is often deceptively high, producing in girls especially 
what the laity regards as an exquisite complexion, though in older women 
and in men such redness of the cheeks is likely to be less generally 
distributed and more patchy. The skilled eye sees the duskiness of 
the underlying cyanosis which shows yet more plainly in the mucous 
membrane of the lips, the skin of the ears, nose and patella, and the 
nails whose pink is replaced by a darker hue or in extreme cases by a 
purplish or blackish gray. 

Cyanosis whether general or local, with or without true dyspnoea, 
ordinarily indicates obstructed venous return, deficient oxidation, or 
commonly both factors such as may result from ordinary suffocation, 
congenital heart disease, asthma, emphysema, pulmonary fibrosis, 
obstructed glottis, trachea or bronchi, as from foreign bodies, croup, 
laryngeal diphtheria, capillary bronchitis or broncho-pneumonia proper, 
mediastinal tumors, or other heart and lung lesions. It occurs also in 
acute diseases such as pneumonia, or pleurisy with either liquid or 
gaseous effusion, and to a slight degree, in severe acute bronchitis. 
Paralysis and spasm, particularly of the diaphragm, may produce marked 



THE OUTWARD SIGNS OF DISEASE. 



cyanosis as may the inhibition of efficient respiration by severe pain. 
No outward sign of disease exceeds cyanosis in importance and one 
short cut to diagnosis lies in the fact that in its extreme form it exists in 
but two classes of walking patients, viz.: — severe emphysema, in the 
adult, congenital heart disease, in the child. It is often associated 
with mere chilling of the body surface, hysteria, neuritis, etc. Local 
vaso-motor relaxation or paralysis is readily distinguished by the lack 
of turgidity of the venous trunks, and it should be remembered that 
certain forms of drug poisoning, especially acetanilide and its congeners 
nitro-benzol, etc., may account for an otherwise inexplicable and extreme 
cyanosis. Through excessive heat loss cyanotic areas are cold save in 
acutely inflamed areas. The slighter degrees are often unnoticed by 
the student but pronounced cyanosis cannot be overlooked. Of the many 
other departures from the normal tint one may mention the yellowish 
brown, dark brown or brownish black of Addison's disease, the peculiar 
bluish or blackish gray of argyria (chronic silver poisoning), the sallow 
tint of malaria and the varying yellows produced by jaundice. Arsenical 
melanosis may exactly simulate Addison's disease but usually diminishes 
under drug discontinuance. The yellowish brown patches of pregnancy 
(chloasma gravidarum) and pelvic disorders are common and easily 
recognized. Streaky pigmentation usually indicates scratching as the 
result of skin parasites or pruritic lesions. Melano-sarcoma is associated 
with a grayish or blackish skin and the urine shows melanin. A 
brownish or dirty gray spotted or patchy discoloration may occur in 
hepatic cirrhosis with or without jaundice and bronzing may be associated 
with combined cirrhosis and diabetes (bronze diabetes). Aside from 
its secondary color manifestations, syphilis in its tertiary and congenital 
form produces a peculiar sallow pallor not easily described, but easily 
learned by observation. So far as the author's observation goes it is 
met with chiefly in old cases of imperfectly treated syphilis, and is likely 
to be associated with other "reminders." Peculiar but indefinable 
forms of pallor may mark the cocaine and opium habitue, best observed 
in the opium dens or the special hospitals of our Pacific Coast towns 
or in the Orient. The author has observed cases in which the appear- 
ance was remarkably like that of chronic nephritis, but more often the 
habit may exist for years without distinctive outward signs. A good 
color should be evident throughout the body, ami the pink skin o\ 
health is too well known to require a description. Vaso-motor contrac- 
tion produces local or general pallor as does an inefficient peripheral 
circulation. A florid face is common in gout, early interstitial nephritis 



Cyanosis in 
ambulators. 



Drug 
poisoning. 



Addison's 
disease. 



Argyria. 



Sallow 

skin. 



Syphilis. 



Opium and 
cocaine 

habit. 



May lack 
sj mptoms. 



Normal 
color. 



8 



MEDICAL DIAGNOSIS. 



Unilateral 
flushing. 



Nephritis. 



Baggy 
eyelids. 



Not path- 
ognomonic. 



Hepatog- 
enous 
vs. 
Hematog- 



Obstruc- 

tive 

jaundice. 



and hepatic cirrhosis, but may be due to idiosyncrasy, acne rosacea or 
exposure. It often suggests an over-luxurious and self-indulgent life 
or the abuse of alcoholics. Unilateral flushing is often observed in 
lobar pneumonia, or mere pillow pressure, migraine, and less commonly 
in irritation of the fibres of the cervical sympathetic as in aneurism 
of the aortic arch. As regards marked color loss or modification in 
connection with chronic diseases, it should be borne in mind that the 
symptom is as a rule one indicative of the advanced stage of the disease. 
Bright's Disease. — Aside from the color changes referred to in the 
preceding paragraph, the external appearances in Bright's disease may 
be somewhat characteristic in chronic interstitial nephritis and yet 

more in chronic parenchymatous 

nephritis and active Bright's. I #*>& {&*%$. 

In the first, the chief indication \ JlW^ *&*?lfc 

is found in the tendency to edema ?& A ' 

of the eye-lids, especially of the i ' ■"- A >d^ 

lower. In such the pale, puffy 

j , , , ,.j £ Fig. 2. — Bright's Disease, ^'rinkled lids. 

and almost translucent hd of 

early morning may later in the day have become shrunken and wrinkled. 
The condition cannot be considered as pathognomonic, but should be 
regarded as suggestive. In chronic parenchymatous and in "mixed" 
nephritis, the face may also appear more or less puffy, sallow or even 
fawn colored. The stages of edema will be discussed under another 
heading. In acute Bright's disease, the peculiar pasty white and the 
evidences of edema are distinctive. 

JAUNDICE. — (Icterus.) Jaundice is either obstructive, as in direct 
or indirect inflammation or obstruction of the common duct, or toxamic, 
the latter form being often wrongly termed hematogenous as opposed 
to hepatogenous. Both types are essentially hepatic as regards the 
source of bile pigment, and "obstruction" and "diffusion" jaundice 
cover nearly every type. There are toxines which act directly upon 
the blood itself (within the hepatic tissues) or affect the hepatic cells. 
Poisoning by phosphorus, potassium chlorate, ether, chloroform, toluy- 
lendiamin, snake venom and arsenic are examples of one form, yellow 
fever, pyemia and malaria of another, while certain diseases are char- 
acterized by a marked associated jaundice. Such are Weil's disease 
and acute yellow atrophy (malignant jaundice). It occasionally com- 
plicates pneumonia, ulcerative endocarditis, syphilis and even influenza. 
The typical mild jaundice is seen in simple catarrh of the bile ducts. 
The term "obstructive" as usually applied covers an obstruction to 



THE OUTWARD SIGNS OF DISEASE. 



the passage of bile from the liver to the intestines with resultant absorp- 
tion into the general circulation. The causes are severe gastro-duodenitis, 
catarrhal conditions involving the duct, gall stone, or parasites in the 
common duct, pressure closure by tumor of that or adjacent structures, 
and very rarely by fecal accumulation, the pregnant uterus, or an 
abdominal aneurism. Strictly speaking all cases of jaundice are 
obstructive as even in the toxic form there is a high viscidity which 
favors absorption. The remarkable jaundice associated with mental 
shock or profound emotion is considered by Herter to be obstructive 
and is probably due to spasm and reversed peristalsis. In one such 
case coming under the author's notice profound jaundice followed 
a mere fit of anger. Urobilin icterus may occur early in hepatic cir- 
rhosis or common jaundice and the substance appears in the urine. 

Symptoms. — The skin, ocular conjunctiva and mucous membranes 
of the throat yield the best evidence, especially if subjected to pressure 
by a microscope slide or a tumbler, or merely blanched by finger pres- 
sure, but even a marked discoloration may be invisible by artificial light, 
though daylight shows a color which on the skin itself varies from a 
dim or brilliant yellow to a deep green or bronze (melasicterus), some- 
times simulating Addison's disease. Two cases of this sort seen 
recently by the author were due to the last stages of cirrhosis of the 
liver and a failing heart associated with general anasarca. The sweat 
and urine are discolored, the latter often yielding the first evidence of 
the condition, the pulse is often slowed, the stools are pale gray, pasty 
and fetid, either constipation or diarrhcea may be present and there may 
be a troublesome pruritus. A marked hemorrhagic tendency is shown 
in severe cases and is of special interest to the surgeon. There may 
be marked mental depression or extreme irritability, and in certain cases 
convulsions, active delirium or a typhoid state, ending perhaps in coma. 
Such cases are most commonly associated with the acute infections 
and the pulse and respiration are markedly slowed. True malignant 
jaundice (acute yellow atrophy) is a rare disease of unknown causation* 
chiefly affecting women and often related to pregnancy, sometimes to 
violent emotion or shock (see p. 308). 

Icterus Neonatorum.— A mild type is extremely common in new- 
born children, occurring during the first 24 or 48 hours and lasting for 
a week or two. It is benign and unimportant. The grave form is due 
to sepsis, usually of umbilical origin, syphilitic disease of the liver or 



Emotional 

jaundice. 



Urobilin 
icterus. 



Outward 
signs. 



Daylight 
necessary. 

Melasic- 
terus. 



Stools, 
sweat, and 
urine. 



Surgical 
bearing 



Icterus 
gravis. 



Mild 

\ 5. 
Fatal. 



*But 250 cases are on record 

1 61 6 (Osier). 



ince the first observation bv Ballonius 



w 



■ 



MEDICAL DIAGNOSIS. 



Localized 

vs. 
General 
sweating. 



Disease 
association. 



Signifi- 
cance. 



Obstruc- 
tive vs. 
Hydraemic. 



Inflamma- 
tory. 



Full of 
vagaries. 



Variable in 
degree. 



congenital absence of the ducts. It is frequently associated with 
hemorrhage from the navel and is a fatal disease. 

DRY AND MOIST SKIN.— Hyperidrosis.— Sweating of the 

hands or feet may indicate idiosyncrasy, debility, or be an indication 
of neurasthenia and especially of sexual neuroses. Unilateral sweating, 
especially of the head or face, like pallor or cyanosis, occurs in pressure 
involvement of the sympathetic, certain migraines and neuralgias. 
Sweating of the head is especially common in rickets and of half the 
body in rare instances of hemiplegia. General sweating occurs as a 
critical phenomena in certain acute diseases, as an associated symptom 
in malarial fever or phthisis and persistently in acute rheumatism, col- 
lapse, severe pain, etc. 

Anidrosis. — A dry skin is associated with diseases causing a profuse 
discharge of fluid by the bowels or kidneys and is a pronounced symptom 
in certain of the cachexias where the skin may be both dry and harsh, 
diabetes, chronic interstitial nephritis and carcinoma furnishing good 
examples. 

Qualitative Changes. — The yellow sweat of jaundice, the blue 
and brown, yellow, red or even hemorrhagic perspiration of hysteria, 
the disgusting odors of bromidrosis or the urinous odor of the sweating 
associated with impaired renal function may be encountered. 

EDEMA.— Three terms are used in this connection, edema proper, 
confined to the actual connective tissues; dropsy, the accumulation of 
fluid in the serous cavities or these combined with edema; anasarca, 
(general edema). The last term however is very generally used to 
indicate a combination of the two. Edema represents an excess of 
transuded lymph over the absorptive capacity of the tissues and may 
be obstructive (passive congestions), hydraemic (toxaemias, infections, 
cachexias) or in many instances a combination of both. Increased 
permeability of the capillary walls is probably a prominent factor in 
the latter if not in both groups, and experiment fails to prove the older 
theory of hydraemic plethora, i.e. increased blood volume and water 
retention. The distinction between inflammatory edema and ordinary 
edema is largely dependent upon the physical constitutents of the 
inflammatory exudate as compared with the simpler transudate. 

A thorough knowledge of the favorite locations and the vagaries of 

this condition is absolutely essential, inasmuch as it may shift its seat, 

obey or disobey the law of gravitation, and vary from swelling of the lids 

and slight pufnness of the ankles, or a localized an gio -neurotic edema, 

| to that distressing condition known as general anasarca, in which the 



THE OUTWARD SIGNS OF DISEASE. 



patient is drowning in his own secretions. The term, angio -neurotic 
edema is applied to a localized and transient firm swelling closely 
allied to urticaria and erythema nodosum, not ordinarily pitting on 
pressure, found in various regions of the body in certain ill defined 
conditions, and is usually of but slight interest or importance. Slight 
and transient edema of the lower extremities is found in cases of anaemia, 
or after prolonged and exhausting tramps in those unaccustomed to 
physical exercise. The characteristic feature of all edemas is the 
appearance of a swelling due to fluid in the connective tissue spaces, 
tending to destroy the normal outline of the affected portion, readily 
receiving and for a variable period retaining indentations from pressure 
of the examiner's finger or constriction due to clothing. In its extreme 
grades the same process tends to produce liquid exudate in such serous 
cavities as the pleura, pericardium, tunica vaginalis and peritoneum, 
producing the condition known respectively as hydrothorax, hydroperi- 
cardium and ascites. Such extreme effusions accompanying general 
edema constitute "general anasarca," which in practice is limited to 
Bright's disease, or a failing heart. As between these two conditions 
the attendant edema at times presents some distinguishing features; 
in heart disease general edema (predominantly obstructive) even 
without general anasarca is associated with cyanosis and in its original 
seat and progress usually follows the law of gravity, commencing in 
the feet and extending upwards. In acute parenchymatous nephritis 
any marked edema (hydremic) usually appears first in the face and 
eyes and extends downwards, being associated with marked pallor, 
unmixed with any considerable degree of cyanosis, unless there be 
obstructive effusion in the peritoneal cavity or thorax, or a complicating 
failure on the cardiac side. Furthermore, the edema of Bright's 
disease as it appears on the body generally or the extremities, is dis- 
tinctly firmer than is a recent cardiac edema, and in those with a delicate 
skin, more especially in children, one may find that the legs present a 
marble appearance, the blue superficial venules contrasting with the 
dead white of the skin. Edema of the cardiac or renal type is markedly 
affected by changes in the position of the patient, that of heart disease 
especially so, the attitude assumed by such a case during any night 
being often indicated in the morning by an increased swelling of the side 
upon which he has lain. Cardiac edema usually appears first in the 
most dependent portion of the body, as in the feet and ankles after a 
day's activity, or over the sacrum in the bedfast. The slighter edemas 
of the lower extremities may wholly or in pari disappear during a night's 



Angio-neu- 
rotic form. 



Salient 
points. 



Cardinal 
signs. 



Cavity 
exudates. 



General 
anasarca. 



Cardiac 
edema. 



Renal 
edema. 



Renal lacks 
cyanosis. 



Marble 
edema. 



Effect oi 
attitude. 



Effect of 



MEDICAL DIAGNOSIS. 



Leathery 
edema. 



Varicose 

veins. 



Important 
variation. 



Associated 
conditions. 



Small 
effusions. 

Large 
effusions. 



Appear- 
ance. 



Shitting 
dulness. 



Ascitic 
wave. 



rest in bed. A certain form of hard edema is occasionally met with in 
those curious cases in which the patient is able to be about for weeks, 
months or years, in spite of a chronic edema of the lower extremities, 
often unrecognized. The skin becomes leathery and pigmented because 
of recurrent eczema, and so resistant that prolonged 'firm pressure is 
necessary to indent it. One should not be misled by an edema of the 
lower extremities, more often unilateral, due to varicose veins. Edema 
of the calves without edema of the ankle or other regions has been 
observed by the author in several cases of heart disease. 

Collateral Localized Edema. — Over all purulent exudates or sup- 
purative inflammation such edema may, but does not always occur, as 
for example, in empyema, mastoiditis, parotitis, pericarditis, hepatic 
abscess, perinephritic abscess, etc. Non-inflammatory circumscribed 
edemas are either angio-neurotic purpurie, giant urticarial or the slight 
edema of the ordinary obstructive type, bilateral if of the cardiac or 
renal type, unilateral if due to the blocking of the local circulation. 
Edema of the arm may be due to the pressure of tumors or enlarged 
glands, to thrombosis and even to massive pleuritic effusion or medias- 
tinal tumors including aneurism. Similar causes will account for local 
edemas of the lower extremities. 

ASCITES. — Fluid in the peritoneal cavity may be part of a general 
dropsy as in heart disease, Bright's disease or obstructive pulmonary 
conditions such as emphysema and fibroid lung, or it may result from 
any form of chronic peritonitis, whether simple, tuberculous, or due to 
tumors, malignant or otherwise. Furthermore, it may be caused by 
portal obstruction, whether due to disease of the liver itself, as in cir- 
rhosis, or to thrombosis or pressure. In tuberculosis, malignant disease 
and most of the cases associated with new growths the effusion is rela- 
tively small. Occurring as a part of general dropsy or portal obstruction, 
the exudate is ultimately large and produces a tense protuberant abdomen 
which tends to broaden in the flanks if the patient assumes a dorsal 
recumbent position. The umbilicus is prominent, percussion reveals 
a dulness dependent upon gravity, and hence shifting as the position 
of the patient is changed. The fluid seeks the most dependent portion, 
the intestines float upward and yield a tympanitic note, shifting exactly 
as does the dulness but being diametrically opposite in position. The 
patient being in a sitting or standing posture a fluctuation wave is felt 
if the abdomen is sharply tapped upon one side just below the line of 
percussion dulness, while the fingertips of the other hand are placed 
opposite. The ulnar surface of the hand of an assistant should be 



THE OUTWARD SIGNS OF DISEASE. 



13 



False wave. 



Sources of 
error. 



Dippim 



Small 
effusions. 



Different!; 
tion. 



firmly applied in the median line between the percussing and receiving 
fingers to interrupt a false vibration in the wall otherwise indistinguish- 
able from the true ascitic wave. Shifting dulness may be interfered 
with by adhesions which prevent the flow of the exudate or hold intestinal 
coils in a fixed relation to the wall; moreover, some time may be required 
for the fluid to change its site, and several moments should be allowed 
to elapse before negative findings are reported. Such effusion makes 
palpation of the spleen, liver or underlying tumors difficult and demands 
that the palpating finger shall be suddenly depressed, preferably both 
during forced inspiration and at the end of forced expiration, the tem- 
porary displacement of the underlying fluid sometimes making the 
underlying structure palpable.* 

The knee elbow position is necessary for the detection of small exudates, 
the dulness then appearing in the very region ordinarily most resonant. 
In massive effusions with excessive tension the ascitic thrill or wave 
may be but rarely is absent. 

The elaborate tables of differential diagnosis seem to the author 
almost futile. Movable percussion dulness in the flanks and lateral 
dulness with central resonance at once rules out pregnancy and pan- 
creatic, ovarian or hydatid cysts, the signs being diametrically opposite. 
Encysted ascites may give rise to insuperable diagnostic difficulties. 
Meteorism, i.e. excessive tympanites yields a universally tympanitic 
note. The ascites of portal obstruction, usually due to hepatic cirrhosis, 
stands by itself, though in any massive accumulation a variable degree 
of edema may be present in the lower extremities. Such an ascites 
without general edema co-exists frequently with emaciation, giving 
rise to the chief form of " poached egg belly." A big belly in a thin 
man invariably means a pathologic condition. 

Character of Ascitic Fluid.— It is usually clear, straw colored, of 
low specific gravity (1010-1015), is albuminous and may spontaneously 
coagulate. The color is slightly darker in cirrhosis than in the ordinary 
secondary forms. In tuberculosis and malignant disease it may be 
hemorrhagic and rarely it is milky or turbid from fat or true chyle. 
The two latter conditions arc readily distinguished by the size of the 
fat globules which in chyle resemble a closely packed field o\' cocci as 
shown on microscopic examination. Mere blocking of the thoracic 
duet may or may not cause chylous ascites; rupture may occur or lilaria 
sanguinis hominis be present. 



Slight or no 
edema in 
cirrhosis. 



Poached 
egg belly 



Color. 



Chylous 

\ 5. 
Fattj 
ascites. 



*As such cases almost invariably need to be lapped the manomvie is of 
slight practical Use. 



14 



MEDICAL DIAGNOSIS. 



Crepitation 
of skin. 



Petechia? 
and ecchy- 
moses. 



Erythema 
nodosum. 



Portal ob- 
struction 



Caput 
medusae. 



Vena cava. 



Internal 
mammary 
and inter- 
costals. 



Visible 
arteries. 



SUBCUTANEOUS EMPHYSEMA.— Aside from malignant edema 
and glanders this condition indicates the entrance of air into the sub- 
cutaneous tissue through wounding or rupture of an air containing 
viscus, as in tracheotomy, cough, rupture of pulmonary alveoli, malig- 
nant ulceration of the esophagus, etc. It offers no difficulty in diagnosis 
because of the pathognomonic crepitation of the distended tissue under 
finger pressure. 

SUBCUTANEOUS HEMORRHAGES.— These will be fully con- 
sidered under purpura, and it need only be said that the discoloration 
of the effused blood is persistent under pressure, that the spots undergo 
the same changes in color as an ordinary bruise, are not elevated, and 
vary greatly in size. The term ecchymosis covers the ordinary petechia 
in the smallest type. When complicating an exanthem as in measles 
or smallpox, they invariably indicate a severe type of disease. In 
chronic diseases they are ordinarily associated with a definite cachexia 
or a hemorrhagic tendency, (see purpura, page 410). In certain obscure 
infections they point to sepsis and if endocardial murmurs are present 
to septic endocarditis. They should not be confused with the nodular 
swelling of erythema nodosum. 

COLLATERAL VENOUS CIRCULATION.— Hepatic cirrhosis or 
thrombosis of the portal veins may produce a very marked and evident 
enlargement of the superficial abdominal veins, and a similar condition 
occurs in thrombosis of the inferior vena cava. The former chiefly affects 
the median region of the abdomen; the relation of its veins to the navel 
suggesting the term "caput medusae," and though the lower thoracic 
veins are involved the whole group lies chiefly within lines dropped 
from the middle of the clavicle to the groin. In the latter the enlarge- 
ment is predominantly lateral and usually less complicated in pattern. 
Unfortunately, admixture of the two may occur as in the case of a 
massive ascites of cirrhosis producing caval obstruction leading to 
enlargement of both groups. If the valves are competent the direction 
of blood flow is easily -determined by stroking the blood from a vein and 
making compression. In any form of intra-thoracic tumor, especially 
those of the mediastinum, visible enlargement of the internal mammary 
and intercostal veins may be evident if the big trunks are compressed. 
Obliteration of the descending aorta at the ductus arteriosus is a clinical 
curiosity, the child usually but not always showing a collateral arterial 
circulation between the subclavian above and the vessels of the lower 
extremity. The arborescent branchings, indicating the diaphragmatic 
attachment frequently observed on the walls of the chest, seem to be 



THE OUTWARD SIGNS OF DISEASE. 



T ~ 



without definite clinical significance. The author's observation would 
indicate that they are most frequently observed in cases showing 
obstructed pulmonary circulation of the chronic type, in chronic cough, 
and not infrequently in connection with general arterial or myo- 
cardial degeneration. Yet they may exist in the normal individual. 

DRUG ERUPTIONS.— Although the various exanthems will be con 
sidered under the related diseases, the question of drug eruption needs 
separate discussion. The iodides may produce acne-like or even varioli- 
form or erythematous rashes, the bromides an acne-like eruption, while 
phenacetin and its congeners, the balsams (such as copaiba), sodium 
salicylate, diphtheria-antitoxin and various other sera are capable of 
producing urticaria or rashes the more exactly simulating scarlatina 
or measles, as fever may be coincident. Hundreds of drugs produce 
rashes in certain individuals and these efflorescences are of so varied a 
nature as to preclude farther description.* 

DESQUAMATIONS.— The chief diseases followed by desquama- 
tion are: — scarlet fever (lamellae), measles (bran-like scales), smallpox 
(crusts), erysipelas (flakes), dermatitis (exfoliation). 

SCARS. — Study the history of scars. The pits of smallpox may 
exclude that disease in the case of a doubtful exanthem. The scar 
of a carbuncle at the back of the neck may suggest glycosuria, multiple 
linear scars at the angles of the mouth congenital syphilis. Linear 
scars on the left hand usually indicate right-handedness and vice versa. 
On the chest small bright shining slightly depressed scars may indicate 
the past use of croton oil, and grouped, finely linear, parallel scars 
over the lungs, liver, heart or spleen suggest cupping for the relief 
of some pain or acute inflammation. Scars at the waist line are common 
in those who have worn electric belts. Those in the supraorbital region 
or thoracic zones may suggest supraorbital or pectoral Zoster. The 
tiny depressed scars of acne affect the chest, shoulders or face and more 
generally distributed suggest syphilis. Those over the heel and 
scapula suggest past bed sores and hence past severe ailments such as 
typhoid. Bullet and stab woundsf may be suggestive in relation to 
character, past occupation and present disease. A seton may have left 
its double scar on back of the neck of some middle aged or elderly man. 
Scars about the neck if long and linear and particularly if left sided 

* For an excellent discussion of this topic see Allbutt's System o\ Medicine. 

fin a clerical appealing patient from a neighboring state such a wound 
proved to have been the result of a drunken brawl in a bawdy house and 
led to an investigation of past and present habits that proved illuminating. 



bower 

thoracic 

veining. 



Simulate 

many 

diseases. 



Important 
inferences. 



Cupping. 



Electric 
belts. 



Bed sores. 

Gunshot 

and stab 
wounds. 



Suicide. 



i6 



MEDICAL DIAGNOSIS. 



Tubercu- 
losis. 



Chancroid 

not 

chancre. 



Lues. 



Epithe- 
lioma. 

Hypoder- 
mic marks. 



Sutures 

and 

fontanelles. 



Tumors 
and nodes. 



in origin and transverse suggest suicidal attempts. They usually run 
downward from the angle of the jaw. Puckered, depressed, irregular 
scars in the cervical triangles, especially the anterior, suggest the slow 
healing of broken down tuberculous glands. Scars evidently due to 
surgical operations usually indicate by their position and extent the 
nature of the operation and its probable cause. Scars in the groin 
do not suggest past syphilis, but rather chancroid. Indeed there is 
not much of positive differential or diagnostic value in syphilitic scars 
save in certain situations or in certain forms of the eruption. In general 
one may say that syphilitic scars may be round, reniform, oval or 
horseshoe-shaped, smooth and seldom traversed by fibrous bands 
except at joints. Lupus may closely simulate syphilis but is not multi- 
form. Frequently there are multiple punctate depressions and some 
old luetic scars are pliable and have a brownish red areola. (See also 
syphilis.) Of special significance are the scars indicating a primary 
lesion, usually, of course, upon the genitals, and those of a destructive 
ulceration of the soft palate. The scar of operation for epithelioma 
of the lips or nose is especially suggestive. Bluish marks from old 
needle coated with oxide of iron may suggest confirmed morphinism or 
cocainism. 

THE HEAD. — Open sutures persisting after the oth month suggest 
hydrocephalus, cretinism or rickets; the posterior fontanelle should be 
closed at the end of the second month, the anterior at the end of the 
j second year; delayed closure or unusual size suggests hereditary syphilis, 
rickets, and cretinism. Bulging fontanelles occur in chronic hydro- 
cephalus, meningeal hemorrhage or inflammation; slight prominence 
and pulsation may occur in any child suffering from febrile ailments 
and is negligible. A sunken fontanelle is present in wasting disease 
and spurious hydrocephalus. 

Cranio-Tabes is indicated by a soft crackle produced by pressure 
over circumscribed areas of the occipital or posterior portion of the 
parietal bones and indicates rickets or syphilis. The pulsating con- 
genital tumors of variable size bulging from the sutures are classified 
as hydrencephalocele, meningocele or encephalocele. Wens or cysts 
are common in the scalp and should not be confused with the deeper 
seated immovable syphilitic nodes representing a gummatous periostitis; 
co-existing brain symptoms suggest similar growths on the inner sur- 
face, their consistence is soft and doughy and there are nocturnal 
exacerbations of the pain. 

Rickets. — A flattened head with elongated vertex, high, square, 



THE OUTWARD SIGNS OF DISEASE. 



17 



often frontally projecting forehead surmounting a small face indi- 
cates rickets and is usually associated with delayed closure of the 
fontanelles, a sweating forehead, muscular weakness, backwardness, 
delayed growth, beading of the costo-chondral articulations ("rickety 
rosary") especially the 5th and 6th, epiphyseal swellings and a palpable 
thinning of the postero -inferior aspect of the parietal and occipital 
bones (cranio-tabes). Deformities of the chest, legs and spine are 
common and the restless little sleeper may have rubbed away the hair 
at the occiput. 

Hydrocephalus. — If the child's head be large but globular rather 
than square, the face relatively small, the space between the eyebrows 
prominent, the fontanelle bulging, the sutures separated and the 
external veins visibly distended a history of excessive cranial growth 
or congenital deformity will be obtained and hydrocephalus is evident. 

Osteitis Deformans. — A marked increase of the head circumfer- 
ence without facial involvement may be associated with the curvature 
of the enlarged shafts of the long bones characterizing the disease. 

Leontiasis Ossea. — Frequently produces marked deformity of the 
skull, particularly in the frontal regions, by osteophytic deposit. 

Facial Hemiatrophy. — Slight unilateral differences may constitute 
degenerative stigmata but in true hemiatrophy the face is mesially 
divided into distinctly different halves, the extreme and apparent 
emaciation of the one side contrasting sharply with the better nourish- 
ment of the other. 

THE EYELIDS. — Dark circles or duskiness most marked in bru- 
nettes are common indications of menstrual disturbance or pelvic disease. 
In both sexes and at any age they may indicate exhaustion from pain, 
insomnia, over exertion, weak heart and exhausting diseases. Puffiness 
or swelling of the lids may indicate Bright's disease, arsenical poisoning, 
anaemia or pertussis. Unilateral swelling may be due to angio-neurotic 
edema or actual inflammations, such as boils, erysipelas or glanders. 
Unilateral swelling with exophthalmos may indicate cerebral throm- 
bosis or tumor pressure. Inflammation of the lids themselves may 
indicate conjunctivitis, simple or specific, and is a common manifestation 
in measles, coryza, iodism, hay fever and eyestrain. Styes, chalazion, 
warts, epitheliomatous or syphilitic ulcers, gouty tophi, lacrymal cyst 
or obstruction and blepharitis marginalis may be evident but need 
no extended description. 

THE EYES. — Many valuable inferences may be drawn from careful 
inspection of the eye and the expression may indicate bad habits con- 



Caput 
quadra- 
ture!. 



Rickety 

rosary. 



A curious 
contrast. 



Trivial or 
important. 



Unilateral 

vs. 
Bilateral. 



vices. 






i8 



MEDICAL DIAGNOSIS. 



Insanity. 



Ocular 
palsies. 



Sometimes 
trivial. 



Of little 
account. 



Bilateral 

vs. 
Unilateral. 






cealed, and often gives a clue to the whole temperament and disposition 
of the patient. The author has been especially interested in the study 
of the eyes of the insane, or those of insane hereditary predisposition. 
Study of the background is of course a matter for special investiga- 
tion (see p. 557). Paralysis of the ocular muscles as indicated by ptosis 
or strabismus at once suggests syphilis, brain tumors, locomotor ataxia, 
cerebral hemorrhage, or in acute diseases, meningitis or profound 
toxaemia (see also p. 560) 

Nystagmus is an involuntary lateral, rotatory or vertical movement 
of the eyeball, and in the absence of extreme refractive errors suggests 
disseminated sclerosis, tumors of the cerebellum or pons, locomotor 
ataxia, or more rarely Friedreich's ataxia or epilepsy. 

The Arcus Senilis. — This is a symptom of little significance when 
seen in persons beyond middle age, as it is merely a local indication of 
the general degenerative process; in younger persons it is of much more 
significance and may be associated with symptoms of general vascular 
changes. It is indicated by a white line surrounding wholly or in 
part the corneal margin. 

Exophthalmos. — In most cases this is bilateral and associated with 
exophthalmic goitre, both eyes being unduly prominent and producing 
a peculiar staring expression, striking and easily recognized. Unilateral 
exophthalmos usually indicates a growth or tumor of some kind in close 
relation to the affected eye. 

Enophthalmos. — This is the opposite of exophthalmos and ordin- 
arily accompanies wasting diseases, severe 
hemorrhage or profuse diarrhoeas. Unilater- 
ally it is found in hemiatrophy or lesions of 
the sympathetic causing malnutrition. 

Corneal Opacities. — These indicate as a 
rule syphilis or a tuberculous tendency but 
they may result from injuries of any nature. 

Cataract. — In many cases this disease of 
the crystalline lens seems to reflect a general 
degenerative process, and should suggest a 
painstaking investigation of the heart, blood 
vessels and kidneys. Juvenile cataract is 
frequently associated with struma or con- 
genital syphilis. 

The Dry and Moist Eye. — If the eye be permanently or for long 
uncovered by the lids, it becomes glazed and dry as also in profound 




Fig. 3-— Exophthalmic Goitre 



THE OUTWARD SIGNS OF DISEASE. 



19 



Often over- 
looked. 



collapse. On the other hand excessive lachrymation may accompany 
irritation of the conjunctiva or photophobia and actual overflow be 
present if the lachrymal duct is blocked or displaced (epiphora). 

THE NOSE. — Saddle nose is discussed elsewhere; a coarse, broad 
organ is seen in certain strumous types, and in cretinism, or may be 
purely racial. Its base may be broad and shapeless in adenoid disease 
and nasal polypi and it may be the seat of distressing vascularity even 
in the temperate individual. Such innocent redness is most frequently Misleading 
due to exposure to the elements, gastric and pelvic disturbances or 
chronic obstructive nasal catarrh. The alae may carry the tuberculous 
or epitheliomatous ulcer. 

Sneezing needs no special discussion though occasionally a trouble- 
some phenomenon.* 

Working Alae. — In neurotic high strung individuals this is commonly 
observed and it also constitutes one of the signs of dyspncea. 

THE EAR.— Earache. — In infants the condition may be indicated 
only by crying, restless movement of the head or rubbing the ear. 
In them as in profoundly toxaemic adults (typhoid, etc.) an acute 
suppurative otitis media may be entirely overlooked until the dis- 
charge appears. The condition is a common one in acute infections 
(especially scarlet fever, influenza, typhoid, diphtheria and measles) and 
its complications are so serious (mastoiditis, meningitis, brain abscess, 
etc.) as to demand careful watching in such cases. Earache may also 
be due to impacted cerumen, abscess or ordinary furuncle of the 
meatus externus, simple catarrhal inflammation and blocking of the 
eustuchian tube, decayed teeth and alveolar abscess, foreign bodies, 
neuralgia, and rarely cancer of the tongue or even innominate aneurism. 

Hematoma Auris. — Bruising and swelling of the pinna is fre- 
quently encountered in the insane. 

Cyanosis and Anaemia are well shown by the external ear. It is the 
most frequent situation for frost bite —and may be the seat of ochronosis Ochronosis 
(blue black cartilages), persistent localized gangrene, f gouty tophi and tophi. 
(gritty sodium urate nodules near the margin of the pinna). 

Discharges of various kinds may be noted. Slight and serou6 if duo 
to meatal eczema, purulent if from purulent otitis media or meataJ 
abscess — clear and serous or primarily bloody in fractures at the 



*ln one instance known to the author persistent sneering excited by 
normal sexual stimuli proved absolutely intractable. 

fin a case of drug habituation a recurrent gangrene of years duration 
affected the car alone 



wr 






MEDICAL DIAGNOSIS. 



Herpes. 



Epitheli 
oma. . 



Syphili 



Acute 
swellings. 



Mouth 

breathing. 



Pallor and 
cyanosis 

Poisoning. 



Diabetes. 
Phosphor- 



Respira- 
tory and 
alimentary 
tracts. 



Uraemia. 

Cadaveric 
emanation. 



Pigmenta- 
tion. 



Exan- 
thems. 



base of the skull — hemorrhage from the lobe is not uncommon in 
hemophilia even without wound or abrasion. Air pressure as in artillery 
concussion or caisson disease may produce hemorrhage. (See also 
auditory nerve and its diseases, p. 564.) 

THE LIPS. — The grouped vesicles of herpes common in coryza, 
pneumonia, malarial fever; the initial lesion of syphilis or the mucous 
patches of the same disease, epithelioma and fissures are some of the 
important conditions to be noted. Epithelioma usually occurs at or 
beyond middle age, ordinarily affects the lower lip, grows indolently 
and exists for a long time without marked involvement of the neighboring 



glands. The initial lesion of syphilis is promptly followed by glandular 
swelling. Mucous patches and syphilitic fissures tend to involve the 
angles of the mouth and leave linear radiating scars, but ordinary 
"cold cracks" or fissures are of no significance. Acute swelling of 
the lips commonly indicates trauma, insect bite, angio-neurotic edema, 
simple abscess, or more rarely corrosive poison, cancrumjris, erysipelas 
or phlegmon. Aside from paralysis or primary mental defects the dry 
lips and open mouth are seen in coma, chronic hypertrophy of the tonsils 
or a nasal obstruction (usually due to adenoids), inflammation of the 

i buccal cavity, the profound exhaustion of certain acute adynamic 
febrile conditions and the terminal stages of chronic disease. The 

t lips are primary indicators of anaemia and cyanosis. 

The Odor of the Breath. — In acute poisoning this may yield 
information of the first importance and the odor of carbolic acid, the 
aromatic bitter-almond odor of hydrocyanic acid and the peculiar smell 
of ether, chloroform, laudanum and alcohol are readily detected. In the 
terminal stages of diabetes mellitus the fragrant fruity breath is most 
suggestive and of serious import. Phosphorous yields an unmistakable 
odor. Foul breath in itself most often indicates improper care of the 
teeth, constipation, chronic naso-pharyngeal catarrh or local disease 
of the buccal pharyngeal or more often the naso-pharynx. The bad 
breath of chronic drinkers is usually due to chronic gastritis. A peculiar 
heavy, aromatic odor is noticeable in so-called uraemia or in the terminal 
stages of failing heart, and a peculiar cadaveric emanation is sometimes 
noticeable at the time of death from exhausting disease. 

THE BUCCAL CAVITY.— The pigmented areas of Addison's dis- 
ease appear here as on the tongue, as do jaundice and cyanosis. In 
acute exanthematous diseases it may be the site of the earliest eruption, as 
in measles where small red spots with a tiny bluish white center appear 
before the development of the cutaneous rash (Koplik's spots). The 



THE OUTWARD SIGNS OF DISEASE. 



21 



papules and vesicles of varicella and variola may be seen and the vivid 
redness of scarlet fever is characteristic. As regards secretion, there 
may be either dryness, such as occurs in mouth breathers from whatever 
cause, or salivation such as accompanies certain of the acute inflam- 
mations or results from the over-use of mercury. Either condition 
may be associated with the hysterical or neurasthenic states, and the 
drooling such as occurs in bulbar palsy, facial paralysis, diphtheric 
paralysis and idiocy is not necessarily attended by actual increase in 
secretion. 

STOMATITIS. — Inflammation of the buccal membrane may take the 
form of (a). Simple catarrh as seen in teething children, acute infec- 
tious disease, or as a result of gastro-intestinal disturbances or direct 
irritation. The condition is characterized by redness, dryness and 
heat of the mucous surface with increase of saliva, discomfort upon 
taking food and moderate fever. 

(b). Follicular or Aphthous Stomatitis. — Is an evidence of 
impaired general health and digestion, common in children, not infre- 
quent in adults, and is characterized by small vesicles soon transformed 
into superficial small ulcers with an inflamed areola, often appearing 
in crops and involving chiefly the edges and the tip of the tongue, the 
deeper folds, or the inner aspect of the cheeks. Constitutional symp- 
toms are identical with those of the catarrhal form but the process 
may be persistent or spread and give rise to a greater degree of pain 
and irritation. 

(c). Parasitic Stomatitis. — (Thrush, muguet, soor, mycotic stoma- 
titis). This is due to the oidium albicans shown readily under the 
microscope. It occurs chiefly under conditions of poor nutrition and 
uncleanly artificial feeding in infants, and is characterized by small 
curd-like deposits appearing first upon the tongue, but tending to 
coalesce spread and even, in extreme cases, cover the whole aural and 
pharyngeal surface. The patches are readily removed and leave no 
ulceration or excoriated surface. The diagnosis depends upon the 
primary location of the lesions, their peculiar superficial nature and the 
use of the microscope. 

Mercurial Stomatitis. -Either through occupational poisoning, 
idiosyncrasy or over dosing, mercury may cause profuse salivation 
associated with spongy swelling and even ulceration of the gums or 
rarely necrosis of (he jaw. A metallic taste and fetid breath with tender- 
ness of the teeth are usually the fust symptoms, and patients under 
mercurial treatment should be carefully watched for increased tlow of 



Dryness 
and 

salivation. 



Hysteri; 



Teething 
children. 



Indigestion 
and malnu- 
trition. 



Seat. 



Oidium 
albicans. 



Curd-like 
deposits. 



Salivation. 



Firs! 

s> mptoms. 



wr^ 



MEDICAL DIAGNOSIS. 



Rare. 

In slums 
chiefly. 

Symptoms. 



Prognosis. 



saliva, and made to bring the teeth sharply together at each visit in 
order that tenderness may be detected. 

Gangrenous Stomatitis. (Noma.) — Fortunately this terrible ail- 
ment is rare, being seldom encountered save in the badly nourished and 
environed children of the slums, in whom it follows convalescence 
from acute fevers, chiefly measles. It is characterized by the appearance 
of a sloughing, spreading ulcer usually on the cheek, rarely on the gum. 
The breath is fetid, there is high fever, profound prostration, delirium 
and diarrhoea. Gangrene rapidly develops in the cheek and may 
involve adjacent structures to a frightful degree, nr appear in other 
portions of the body. The disease is almost invariably fatal. 

Ulcerative or Fetid Stomatitis. — This condition stands midway 
between the aphthous form and cancrum oris, occurring during dentition 
usually; but rarely in adults, and at times seeming to be epidemic. 
The gums are usually swollen and spongy, bleed readily and show 
linear sloughing ulceration. The process occasionally involves the 
tongue, cheeks and inner surface of the lips; the submaxillary glands 
enlarge and the constitutional symptoms are often severe and associated 
with extreme prostration and marked febrile reaction. Rarely, and 
chiefly in marasmic children, the process assumes a type suggesting 
noma, but ordinarily recovery occurs in a week or ten days. 

THE TONGUE. — In many diseases, acute or chronic, whether affect- 
ing proximate or remote structures the condition of the tongue may as- 
sist diagnosis, prognosis and treatment. A lightly coated tongue may be 
found in persons of perfect health, or may indicate fever, disease of the 
naso-pharynx, gastro -intestinal disturbances, mere smoking, drinking, 
or the possession of bad teeth. A heavy pasty yellow coating in usually 
indicative of catarrhal gastritis, naso-pharyngeal catarrh or some dis- 
turbances of the digestive tract. A clean tongue may be and often is 
associated with gastric hyperacidity or even ulcer. In chronic dys- 
pepsias the tongue is flabby, often enlarged and laterally indented by 
the teeth; in the typhoid state the heavily coated tongue is ordinarily 
bright red along its margin and at its tip, which oftentimes shows a 
triangular red area. In all conditions of profound toxcemia and exhaus- 
tion it tends to become brown, dry and fissured, is tremulous, slowly 
protruded and retracted slowly or only when ordered. Such a tongue 
and its congener, the red, shiny, dry, " beefy" tongue indicates a bad 
prognosis. The so-called strawberry tongue is frequently seen early 
in an attack of scarlet fever. Its name is derived from its bright red 
surface-points due to swollen papillae emphasized by a white pasty 



Severe 
type. 



Seat. 



Prognosis. 



Coated 
tongue. 



Gastric 
ulcer. 

Typhoid 
tongue. 



Reefy 
tongue 



Strawberry 
tongue. 



THE OUTWARD SIGNS OF DISEASE. 



2 3 



Scar 



Tremor and 
atrophy. 

Large 
tongue. 



Pigment. 



background. A unilateral coating suggests hemiplegia, but may be 
due to bad teeth on the affected side. Deep fissures along the edge Fissures 
suggest past syphilis; it reflects the general pallor of anaemia and the 
cyanosis of cardiac or pulmonary disease, and one may detect a tuber- 
culosis or epitheliomatous ulceration or scars suggestive of the tongue 
biting of epileptic seizures or glosso-labio-pharyngeal paralysis. Uni- 
lateral atrophy, the tremor and jerky protrusion of marked alcoholism 
or actual delirium tremens and muscle spasm, associated with paresis 
must not be forgotten. Marked enlargement may be due to acute 
glossitis or to acromegaly and myxcedema. Tumors must be thought 
of as well as the various acute conditions affecting the mucous membrane 
of the mouth. Various pigment deposits may occur here as in other 
portions of the oral mucous membrane, the most marked are the deep 
brown, purple or black deposits of Addison's disease, and the yellow 
tint of the under surface in jaundice. A black tongue usually indicates 
the use of iron, bismuth or charcoal, the brown discolor ations are 
most commonly due to the use of tobacco, liquorice or chocolate, less 
often to laudanum and rhubarb. The corrosive acids either whiten 
the surface (oxalic, carbolic, sulphuric acids as well as ammonia and 
corrosive sublimate) or yellow it as do chromic, hydrochloric, and nitric 
acids, while caustic soda or potash and the nitrate of mercury redden it. 
It may be the source of persistent hemorrhage in purpura or hemophilia. 
The term "geographic tongue" is applied to the annular red patches 
due to eczema, which spread peripherally to form eccentric areas. 

Leucoplakia Buccalis. — (Buccal psoriasis, leucoma, ichthyosis). Is 
characterized by non-ulcerative and irregular smooth, white, firm 
raised patches. The smoker's patch occupies the dorsal surface of 
the tip as a pearly yellow, or perhaps reddish plaque. 

The Gums. — Marginal redness is usually of little significance, being 
attributable to uncleanliness, and dental caries, though it is thought 
to have some significance in young persons as an indication of tubercu- 
losis and is present in several of the cachetic states. A grayish or bluish 
gray or black line may indicate lead poisoning but this line is rather a 
linear series of dots and lines about one mm. from the actual margin. 
Cabot justly protests against the use of the term "blue line" in these 
cases. More rarely a similar greenish blue line is present from copper 
poisoning. Swollen, spongy or bleeding gums are present most com- 
monly in mercurial stomatitis and conditions of great debility and 
exhaustion. In scurvy it constitutes one of the prominent symptoms 
and is present oftentimes in the various cachexias. In neglected eases 



Black 

tongue. 



Poisoning. 



Hemor- 
rhage. 



Eczema. 



Smoker's 
tongue. 



A mis- 
nomer. 



2 4 



MEDICAL DIAGNOSIS. 



of the typhoid type accumulation of oral debris from the so-called sordes. 
Dental abscesses and various growths such as epulis may also occur 
in this region. Around the base of the gums as well as in the more 
readily visible portions of the buccal mucous membrane may be seen 
the mucous patches of syphilis. 

The Teeth. — As regards the period of eruption of the first and 
second sets of teeth, a wide margin must be allowed in both directions, 
an unusually early appearance being of no significance while a greatly 
delayed eruption is usually indicative of malnutrition and often asso- 
ciated with distinct developmental defects. The disturbances of denti- 
tion while doubtless exaggerated are nevertheless important and are 
accountable for many ailments of infancy. Any doubting physician 
would be convinced of this fact if he himself should for a time suffer 
from similar inflammations from whatever cause. On the other hand 
he should not too readily adopt the disturbance of dentition as a cause 
of disease lest he overlook more concrete and serious conditions.* 

Hutchinsonian Teeth. — These teeth, characteristic of congenital 
syphilis, are often more or less closely simulated and a positive diagnosis 
should be made only when they present the following typical character- 
istics: — In the second dentition, peg-like, rounded, upper central 
incisors usually discolored, irregularly placed, separated and bearing a 
single well defined notch at their cutting edge or even less characteristic 
teeth may be termed syphilitic if associated with a history of middle 
ear disease, keratitis, sore bottom, and fissures or residual linear scars 
at the angles of the mouth. Transverse grooves or furrows like those 
of the nails indicate past severe illness, dentated cutting margins are 
common in malnutrition and pitted teeth may be due to stomatitis. 
Early decay is common in pregnancy, phosphorous poisoning, rickets, 
diabetes and other forms of severe malnutrition and the importance 
of good teeth in connection with chronic dyspepsia is too little appre- 
ciated by the practitioner. Many obstinate and persistent ailments 
are promptly cured by proper attention to the remaining teeth, the use 
of dental bridges, or extraction and the substitution of properly fitting 
plates. 

* The normal periods are in months: — First dentition: — two lower central 
incisors 6-9. Four upper incisors 8-12. Four anterior molars and lower 
lateral incisors 12-15. Canines 18-24. Posterior molars 24-30 (in all 
20 teeth). Permanent set {in years): — Molars, first set 6; second set 12-15; 
third set 17-25. Incisors 7-8. Bicuspids 9-10. Canines 12-14. It fol- 
lows that at the end of the first year there are 6 teeth; at the end of the 
second 16, and that the first dentition should be completed in two and one- 
half years. 



THE OUTWARD SIGNS OF DISEASE. 



2.5 




Perfora- 
tion and 
paralysis. 



Teeth grinding is a common symptom of reflex irritation or gastric 
disturbance in children and is rarely due to the commonly accepted 
cause, worms. 

The Jaws. — The high arched palate so commonly associated with 
the neurotic temperament is readily noted as is the massive lower jaw 
of acromegaly. The prominent square jaw and the receding chin 
are universally associated with firmness or the lack of it, but the con- 
clusions are subject to doubt or at least to many exceptions. Spasm 
of the jaw suggests hysteria, tetanus, strychnine poisoning, trismus 
neonatorum, reflex spasm in childhood or irritation of cerebral origin. 
Its opposite, paralysis may be noted in pontine hemorrhage, neuritis, 
brain tumor, meningitis, etc. The jaw move- 
ment may be more or less impeded in such 
diseases as quinsy, mumps, and trichiniasis. 

The Soft Palate. — Syphilitic perforations 
have been referred to. Paralysis is usually due 
to diphtheria, less commonly to cerebral tumor, 
meningitis, caries and bulbar palsy. 

THE HANDS.— Aside from the stigmata of 
occupation, the hands afford much information 
of the most suggestive sort. The handshake 
itself may indicate a lack of vigor; tremor may 
often be felt as well as seen and what seems 
like a mere formality may contribute largely to 
diagnosis and prognosis. Persons of the tuber- 
cular type often have hands, delicate and femi- 
nine, easily compressed and weak in grasp and 
the flexible slender hand of the nervous person, 
sharply contrasts with the clumsier one of the 
phlegmatic type. In wasting diseases the hand 
feels hot, dry and flabby and emaciation is easily 
recognized, as are deformities of the joints clue 
to chronic rheumatism, gout or rheumatoid 
arthritis, the clubbing of the finger tips o\ 
chronic pulmonary disease and the giant hand 
of acromegaly. 

Finger Nails. — Chronic indolent ulceration surrounding the nail 
suggests syphilis or marked malnutrition. The incurred nail associated 
with a clubbed finger tip is a sign of chronic pulmonary or cardiac dis- 



The 

handshake 



Fig. 4. 

1. 1 leberden's nodes. 

2. Syphilitic dactylitis. 
.?. Clubbed fingers. 

4. Arthritis deformans. 

5. Spade hand of aero 

megaly. 



ease of the obstructive type, or an advanced pulmonary tuberculosis. 



The grip. 



Wasting 

disease. 



Deformi 

ties. 



Onychia 



Clubbed 
fingers. 



J 



w 



26 



MEDICAL DIAGNOSIS. 



Brittle or 
split nails. 



Transverse 
ridges. 



Syphilis. 
Periostitis. 



Rachitis 

and 

scurvy. 



Conges- 
tion, edema 
and 
cyanosis. 



Bubo. 



Hernial 
openings. 



Brittle, striated or split nails most frequently occur in connection with 
gout, peripheral neuritis, and prolonged exposure to the X-Ray. Most 
important of all to the case-taker are the transverse ridges indicating 
a past severe illness. These are easily noted, last for a period of over 
6 or 8 months, and by their proximity to the matrix indicate approxi- 
mately the date of the illness. 

THE ARM AND LEG.— Many of the conditions affecting these ex- 
tremities such as edema, pain and tenderness have been discussed 
under their appropriate headings. Hard circumscribed bilateral swell- 
ings upon the ulna or tibia are usually syphilitic nodes, and the more 
diffuse, bilateral, painful enlargements of the tibia with nocturnal 
exacerbation are also usually syphilitic. Localized edema with heat 
and redness and severe deep seated pain over long bones and espe- 
cially the tibia suggest acute periostitis which may lead to chronic 
fistulous openings indicating secondary necrosis. Enlargement of the 
lower end of the radius suggests rachitis, and exquisitely tender 
brawny induration over the femur in children is an almost constant 
sign of scurvy. Varicose veins are common in the lower extremities 
and may be bilateral or unilateral, are often associated in middle aged 
or elderly persons with chronic indolent ulcers and may produce a 
misleading edema. Congestion and edema with pain and localized 
tenderness suggest phlebitis, and perforating ulcer usually under the 
ball of the great toe may be present in locomotor ataxia or rarely in 
diabetes. Deep cyanosis of the foot or toes suggests Raynaud's disease, 
frost bite or the early stage of an actual gangrene which may be associated 
with injury, arterio-sclerosis, embolism, diabetes, frost bite, ergotism, 
Raynaud's disease and rarely, it is claimed, exophthalmic goitre. Mottled, 
dusky redness and pain over the sole of the foot may indicate erythro- 
melalgia. The presence or absence of pulsation should be carefully 
noted in connection with painful diseases of the lower extremities 
especially as indicating arteritis or incipient gangrene. The enlarged 
glands in the groin or femoral triangle suggestive of syphilis, chancroid. 
Hodgkin's disease, leukemia, malignant disease, etc., should be noted as 
well as the enlarged epitrochlear gland of syphilis above the inner condyle 
of the humerus. Transient nodular swellings usually painless and subsid- 
ing with bruise like color changes are common in erythema nodosum. 
The region of the hernial opening should be carefully explored, particu- 
larly if otherwise unexplainable pain or evidence of intestinal obstruc- 
tion are present. A discussion of the various deformities and joint 
diseases does not come within the scope of this book. 



THE OUTWARD SIGNS OF DISEASE. 



2 7 



THE BACK.— The deformities of the spine are essentially four in 
number. (1). Lateral curvature (scoliosis) most frequent in young girls 
and due to faulty position in standing and sitting, to muscular weakness 
or to general debility as from rachitis. It also results from chronic 
disease of the lung or pleura, paralyses affecting posture and mollities 
ossium. The deformity is seldom extreme in its ordinary form and is 
usually remediable. (2). Lordosis or exaggerated normal curve 
as exemplified in the later stages of pregnancy. It suggests that con- 
dition, abdominal tumors, ascites and pseudo-muscular hypertrophy. 
(3). Kyphosis, if sharply angled posterior projection of the spine is 
present Pott's disease (spinal caries) or mollities ossium are suggested. 
It is common however as a simple backward projection in the* dorsal 
region, in rickets, debility and chronic emphysema. Immobility of the 
spine: — Temporary stiffness may be due to muscular strain or rheuma- 
tism, and chronic rigidity indicates arthritis deformans, paral- 
ysis agitans, Pott's disease or the curious spondylitis rhyzomelique, 
a painless disease of middle aged men, commencing in the hip 
joints and extending upwards to the spine and shoulder, the result 
being a rigid kyphotic spine and anchylosis of other affected joints. 
In other cases the disease originates in and is limited to the spine. 
Tumors and Swellings. A great variety are discussed in surgical 
and orthopedic works and the congenital spina bifida abscesses due 
to caries, fatty tumors, bed sores and sacral edema are frequently 
encountered. 

THE JOINTS.— The following points should be determined:— (a). 
Presence, extent and character of redness, swelling and deformity, (b). 
The position assumed, (c). Heat. (d). Tenderness, (e). Fluctua- 
tion or edema, (f). Degree of movement in relation to pain. (g). 
Presence of crepitus, (h). Outline of bony structures, (i). Anchylosis. 
(j). Atrophy, (k). Contractures. (1). Associated or antecedent injury, 
suppuration, excessive exhaustion, fatigue or other recognized causative 
or predisposing factors. In the knee joint, fluid is most readily detected 
by fully extending and supporting the extremity and making down- 
ward pressure upon the patella which may be felt to tap the articular 
surface (floating of the patella). Ordinarily the outline of the distended 
synovial membrane in such a case is characteristic. 

General Comment. — It should be remembered that in acute rheuma- 
tism the larger joints are chiefly and primarily affected, usually bilater- 
ally and in a definite order, and that the skin is moist, the sweat 
acid, fever and anaemia marked. In acute gout a single joint, usually 



Deform- 
ities. 



Wide 
variation 
in signifi- 
cance. 



Floating 

patella. 



joints 

chiefly. 



yA 



28 



medical Diagnosis. 



Chiefly 
small joints 



Barometric! 
influence. 



Resists 
salicylate; 



Secondary 
to acute 
infection. 



A common 
error. 



Another 
source of 
error. 



Charcot 
joints. 



Hysteria 
and chore? 



Phthisis. 



the great toe is primarily affected, a preference is shown for the small 
joints, the actual pain and throbbing are greater and more par- 
oxysmal than in rheumatism in which they are chiefly excited by move- 
ment though of the slightest degree. In chronic rheumatism deformity 
is as a rule not extreme, fever is absent, changes of the weather mark- 
edly affect it and exacerbation and subsidence are the rule. In arthritis 
deformans an acute primary attack cannot at first be distinguished 
from acute rheumatism, but it is more persistent, yields less readily 
to specific treatment (salicylates, etc.), and tends ultimately to become 
chronic, the joints grating on movement, deforming and becoming 
fixed. Both large and small joints are involved and the disease may 
become* almost universal. 

Septic Arthritis. — This occurs chiefly in the course of or immediately 
following acute infectious diseases, especially scarlet fever and dengue, 
and is common in pyaemia and gonorrhoea. The infantile form of 
septic arthritis may occur without an assignable cause and progress 
rapidly to suppuration. The various tuberculous lesions are too 
numerous to permit of discussion in this volume. One of the commonest 
and most regrettable of medical blunders is involved in the misdiagnosis 
of osteo-myelitis too frequently diagnosed as rheumatism. The 
urgent need of radical surgical measures in these cases makes it impor- 
tant that one should remember that it is the epiphyses that are chiefly 
involved rather than the joint itself and that the disease is distinctly 
septic in type, pain extreme, deep seated and boring, and further that 
as in rheumatism, several joints may be involved. So also in the hem- 
orrhagic diathesis such as hemophilia, scurvy and purpura joint, affec- 
tions occur either rheumatic in character or due to hemorrhage. 

In connection with organic nervous disease we meet with arthrop- 
athies. In locomotor ataxia and syringomeylia, one of the large joints, 
most frequently the knee, ankle or hip may become suddenly swollen 
with or without pain and go on to rapid disintegration (Charcot joints). 
In connection with all chronic joint affections there may be marked 
muscular atrophy but the electrical reactions are preserved. Hysterical 
joints may create much confusion being excessively tender and fre- 
quently contractured. Chorea is frequently associated with what is 
probably a true rheumatic arthritis and myelitis may be accompanied 
by the same condition. 

VOICE AND SPEECH.— One should train himself to carefully 
note variations from the normal healthy tone and enunciation. Even 
the laity recognizes the curiously soft high-pitched voice of the phthisical 



THE OUTWARD SIGNS OF DISEASE. 



20 



patient, often indeed encountered in those showing merely a tuberculous 
predisposition; so also one recognizes the harsh voice of the prostitute 
and the thick muffled tone of the victim of tonsillitis, adenoid disease, 
or otherwise obstructed nasal passages. Hoarseness and aphonia 
are at times symptoms of great importance, pointing to acute or chronic 
laryngeal diseases; the whispering voice may be due to tuberculosis or 
malignant laryngitis, hysteric aphonia or paralysis of the abductors , 
due oftentimes to the pressure of an aneurism or mediastinal growth 
upon a recurrent laryngeal nerve. Slow, scanning, syllabic speech 
combined with an intention tremor suggests disseminated sclerosis 
or very rarely Friedreich's ataxia. In paralysis agitans the crescendo 
speech may be encountered; in this a sentence is begun slowly and 
with hesitation, but increases in rapidity and ends in a storm of words. 
In glossolabio -pharyngeal paralysis, amyotrophic lateral sclerosis and 
pseudo-bulbar paralysis, one encounters a mumbling speech, associated 
with tremor and atrophy of the tongue and curious immobility of the lips. 

APHASIA. — For normal processes it is necessary that the centres 
and mechanism for the perception and recollection of spoken and 
written or printed words, of articulation and of association, should 
be normally active and harmoniously interacting. It is evident that 
various disturbances may exist according to the character and location 
of the lesion. Furthermore, that we must discriminate between aphasia 
and the cases of paralysis or palsies of the muscles of articulation 
(anarthria). True aphasia is usually of central origin, the peripheral 
mechanism being unaffected. 

Motor Aphasia. — This must be recognized as distinct from sensory 
aphasia, it is characterized by inability to voluntarily express by speech 
(aphemia), by writing (agraphia) or by gestures (amimia) what may be a 
perfectly clear mental image. 

Sensory Aphasia, on the other hand, indicates a failure to understand 
or recognize spoken words (auditory aphasia, word deafness) or written 
words (visual aphasia, word blindness). A large number of subdivisions 
occur under both types, such as the loss of power to carry a tunc 
or write music, or on the sensory side a failure to interpret or recognize 
musical sounds or notation. Still another variety (paraphasia) occurs 
in which wrong words or characters are spoken or written, or the same 
word repeated. 

Apraxia. —By this is meant a loss o( the faculty oi recognizing or 
appreciating the identity, nature and uses oi objects, and here again 
one has various sub-divisions, such as mind blindness (visual amnesia), 



The 
prostitute. 

Nose and 
throat. 

Hoarseness 

and 

aphonia. 



Syllabic 
speech. 

Crescendo 
speech. 



Mumbling 
speech. 



Anarthria 

vs. 
Aphasia, 
aphemia 
and 
amimia. 



Word deaf- 
ness and 
blindness. 



Paraphasia 



A 



r 



30 



MEDICAL DIAGNOSIS. 



Purposive 
move- 
ments. 



Extension 

increases 

them. 



mind deafness (auditory amnesia), as well as terms indicating an 
inability to recognize and interpret odors, tastes, etc. 

TREMOR.— Modes of Testing Tremor.— To distinguish between 
passive tremor and intention tremor, direct the patient to make some 
movement such as is involved in taking up and fastening a collar button, 
buttoning the vest, or drinking a glass of water. In this latter variety 
the tremor is greatly increased by the co-ordinate movements involved, 
I and indeed may be wholly absent when the patient is at rest. All 
' tremors of the extremities are increased by extension, therefore the 
patient should extend the arm or leg in front of him, keeping the fingers 
or toes separated as widely as possible. Again if the tips of the fingers 
are allowed to rest upon the physician's palm a vibration otherwise 
imperceptible may be readily detected. Tremors of the muscles of 
the face may be emphasized by the firm closure of the eyes, elevation 
of the eyebrows, or by drawing the corners of the mouth down or out- 
ward and tremor of the tongue is markedly increased by protrusion. 
In the case of individual muscles or muscle groups in various portions 
of the body, putting these in action or under continued strain usually 
increases their movement. One should note whether he is dealing with 
a local or general, passive or intention, course or -fine, rapid or slow, 
regular or irregular tremor. 

Conditions with which Tremor is Associated. — The tremor of 
advancing age and the extremely rare condition of congenital or inherited 
tremor are unimportant, as are those due to temporary nervousness 
or overstrain and the excessive use of tea, coffee or tobacco. Tremor 
in acute disease usually indicates a profound toxaemia, being one of 
the unfavorable symptoms, for example, in typhoid fever, and it is often 
encountered in the typhoid state whatever be the underlying original 
disease. In alcoholism it is not only a prominent feature of delirium 
tremens, but may often enable the physician to detect a recent debauch 
or present excessive potations, and if marked suggests the onset of an 
acute attack. Such a tremor is ordinarily fine, regular and persistent, 
and very similar to that of drug habituation. 

Exophthalmic Goitre. — In this disease the tremor is fine and rapid 
and if associated with a large thyroid and rapid pulse with or without 
exophthalmos, the diagnosis is made. Every suspected case should 
be tested for tremor by taking the finger tips in the palm of the hand. 

Paralysis Agitans. — This is ordinarily a relatively slow tremor, 
first affecting the thumb and forefinger and causing a rolling movement 
of the thumb over the forefinger known as the "pill-making" or "bread- 



Facial 

tremor. 



Tongue. 

Action 

vs. 
Repose. 

Fine and 
coarse. 

Trivial 
tremor. 



In acute 
disease. 



Alcohol- 
ism. 



Rapid 
and fine. 



"Pill- 

rollim 



THE OUTWARD SIGNS OF DISEASE. 



3 r 



crumbling" tremor. It disappears during sleep and unlike intention 
tremor is checked by volitional movement. In its more advanced 
form it may involve the arms, legs and head. 

Mineral Poisoning. — Any case of otherwise unexplained tremor 
should suggest the possibility of poisoning by some metal or drug, such 
as cocaine, opium, arsenic, lead or mercury. 

Intention Tremor. — This condition suggests always disseminated 
sclerosis, but may be met with in a marked form as a senile tremor 
or even in lead poisoning. 

Tremor of the Muscles of the Face. — Twitching or flickering of 
the facial muscles strongly suggest profound neurasthenia, paresis or 
chronic alcoholism. In progressive muscular atrophy juvenile or spinal 
(adults) it may be observed in other regions as well. 

SPASM, CRAMPS, AND CONVULSIVE SEIZURES.— The term 
cramp should be reserved for a painful, spasmodic, muscular contraction 
temporary and localized. It may be associated with alcoholism, gout, 
diabetes, Bright's disease, hysteria, or excessive muscular fatigue and 
most commonly involves the calf muscles. The constant over use of one 
set of muscles such as is met with chiefly in the occupational neuroses 
as typified by the so-called scrivener's palsy may take the form of cramp, 
though frequently a simple spasm, mere weakness or an actual paralysis, 
(see p. 42). The term is quite correctly applied to painful spasm of 
the viscera such as is involved in renal or biliary colic. 

Wry Neck. — This may be congenital, traumatic or purely spasmodic 
and save for cases associated with actual traumatism at or subsequent 
to birth, represents a disturbance affecting the spinal accessory nerve. 
In true congenital wry neck there is atrophy of the sterno-mastoid 
(usually the right) and facial asymmetry, as opposed to mere muscle 
callous due to rupture at the time of delivery. Spasmodic wry neck may 
be tonic, clonic, or more rarely combined, and may follow injury or 
exposure or be a true neurosis. In any event the muscle group of 
spinal accessory innervation is chiefly involved and the spasm of the 
rotators elevates the chin and swings it towards the unaffected side. 
The shoulder may be raised and the head drawn decidedly backward 
if the trapezius be much involved. Bilateral spasm drawing the head 
back and the face upward is rare. The clonic spasms are particularly 
distressing and unfortunately the disease usually tends to become fixed. 

Nodding Spasm. — This condition is usually a neurosis particularly 
in its adult form. In children it may be mimetic, retlex (teething), 
or associated with rickets. Ocular spasm especially nystagmus and less 



Dissemina- 
ted scle- 
rosis. 



Fibrillary 
flickerings. 



Gastrocne- 
mius 
cramp. 



Occupa- 
tional 
cramps. 



Cramp 
colics. 



Causes. 



Trapezius 
involve- 
ment. 



Bilateral 

w rv nock. 



spasmus 

nutans. 



JL 



3 2 



MEDICAL DIAGNOSIS. 



Parts 

involved. 



Trous- 
seau's 
sign. 



often strabismus may be associated with it. The oscillations cease 
during sleep and are increased by excitement or when under observa- 
tion and associated mental defects are occasionally noted. The reflex 
cases may be purely transient. 

Tetany. — This condition is entirely distinct from tetanus, being 
merely a bilateral tonic spasm of the extremities, either continuous or 
paroxysmal, most commonly involving the feet and hands, less often 
the face, neck and jaw (trismus), rarely affecting the muscles of the 
trunk. Excessive muscular irritability is evidenced by the active 
contraction following compression of the brachial artery (Trousseau's 
sign) or even the lightest tap. Paresthesia may follow the lightest 
presure upon a sensory nerve, fever is sometimes present, and the disease 
is usually paroxysmal in type and associated with marked debility. 
Among the rare causes are gastric lavage, (in cases of dilatation), and 
removal of the thyroid gland. The disease is sometimes epidemic 
but is extremely rare in this country. 

Paramyoclonus Multiplex. — This syndrome covers those peculiar 
cases occurring chiefly in males and of unknown causation, in which 
clonic with occasional tonic spasm occurs, either constantly or paroxy- 
smally, unaccompanied by sensory disturbances. These are usually 
symmetrical and rhythmical and cease during sleep. 

Athetoid Movements. — These curiously deliberate, writhing, twist- 
ing movements of the fingers and hands, more rarely of the feet and 
toes, may result from infantile palsy or follow hemiplegia in adults. 
They are slower and less jerky than the movements of chorea with 
which they are sometimes confounded. 

Myoidema. — One frequently notes a marked fleeting, localized 
contraction if a muscle be sharply tapped with the finger. This phenom- 
enon is especially common in the muscles of the chest in connection with 
tuberculosis, but is not a sign of marked importance. 

Catalepsy. — This extraordinary symptom indicates hysteria, but 
may be encountered in melancholia, brain tumor, meningitis, or be 
produced by hypnosis of which it constitutes the secondary stage. 
The patient appears asleep and the limbs remain for minutes or hours 
in the position in which they are placed. It is often auto-hypnotism, 
the eyes are closed, rolled upward, the pupils contracted and sensibility 
to pain and special and general sensation is abolished. The duration 
of such attacks is often short, but in the cataleptic sleeping girls (of 
the newspapers) the attacks may endure for years, such cases being 
able to hear, take occasional nourishment, and respond to other stimuli. 



Auto- 
hypnotism. 



THE OUTWARD SIGNS OF DISEASE. 



33 



Hysteria. — The actual study of cases is necessary to an understanding 
of the physiognomy of external appearances of this extraordinary 
condition, but once a large number have been carefully observed, the 
difficulties are largely done away with. The topic has been dealt with 
entire and the reader is referred to page 615. 

INFANTILE CONVULSIONS.— Attacks precisely similar to those 
of epilepsy or differing in some particulars may be observed in both 
children and adults. In the former, they may be due to general 
malnutrition, either primary or secondary to disease, to rickets, to 
fever as is so frequently seen at the onset of acute infectious diseases, 
rarely in congestion of the brain and quite commonly as reflex phe- 
nomenon due to peripheral causes. Disease or irritation such as 
dentition with its associated digestive disturbances, phimosis, diseases 
of the eye and ear, and possibly intestinal worms may be causative. 
Convulsions accompany the larger number of cases of cerebral dis- 
ease in children and one observes occasionally in young infants a 
gradually diminishing tendency to convulsive seizures from the time of 
their birth. 

Symptoms. — Aside from the usual premonitory symptoms such as 
slight switching, teeth grinding, restlessness or irritability the attack 
is precisely similar to that of epilepsy. The diagnosis in repeated 
attacks most often depends upon their subsidence or disappearance, 
when a cause is found and removed. The infant mortality from this 
source is considerable and unfortunately a large number of true epil- 
epsies commence during the first three years of life, over a third of those 
investigated by Osier occurring in the first year. 

Diagnosis. — In any case the first thought should be of the onset of 
an acute infectious disease, or simple overloading of the stomach and 
indigestion, two causes which account for by far the greater number 
of such attacks. If the condition is persistent we have not only to think 
of epilepsy but of the various diseases affecting the brain and its cover- 
ings. Adenoid disease should always receive consideration. 

STATION. ATTITUDE. GAIT.— Static ataxia is tested by hav- 
ing a patient stand with heels and toes together and eyes closed. 
Marked swaying (more than an inch or so of excursion") suggests loco- 
motor ataxia, Meniere's disease or a lesion of (he mid cerebellar lobe. 
The patient may sway violently and fall unless closely watched.* 

DECUBITUS.- -In the bedfast patient, its chief divisions are the active 



Simulate 
epilepsy. 



Malnutri- 
tion, tox- 
aemia.reflex 
causes. 



Mortality 
Age. 



Seek a 
cause. 



Test tor 

static 

ataxia. 



* One sufferer aptly described his sensation as that of a 
clothes line." 



chicken on a 



JA 






MEDICAL DIAGNOSIS. 



Active 
vs. 
Passive. 



and passive, dorsal and lateral and it varies with the condition of the 
patient and the localized nature of his disease. Even the severer types 
of pneumonia do not rob the patient of his active decubitus, which 
contrasts strongly with the passive decubitus typified by severe typhoid 
fever in which the patient lies relaxed and helpless, must be moved from 
side to side, and occasionally straightened out to relieve the cramped 
posture or prevent his gravitating to the foot of the bed. The terms 
dorsal and lateral explain themselves but it is important to note whether 
the patient changes voluntarily from one to another or whether through 
extreme weakness, or because movement to a changed position involves 
increased pain, he maintains a fixed posture. In general the man with 
appendicitis lies on the back, often with the right knee drawn up, or 
in general peritonitis with both knees so placed. In severe abdominal 
colics (hepatic, renal, etc.) the knees are often drawn close to the belly 
and the lateral coiled position is common. In the early stage of a 
pleurisy, with or without pneumonia, the patient usually lies upon the 
affected side, probably to limit movement of the affected lung and 
facilitate that of the sound one, later in the disease the position is more 
variable. An acute meningitis is characterized by rigidity and retrac- 
tion of the head and neck giving it a distinctive appearance. In a severe 
rheumatic fever and certain cases of infantile scurvy and rickets the 
patient lies rigidly in a dorsal position, his whole attitude expressing 
apprehension when his bed is approached or any effort made to 
examine or handle him. In cases of heart disease in which compensa- 
tion has failed through whatever cause, and in asthma and severe 
emphysema or laryngeal obstruction, one is likely to find the peculiar 
sitting posture indicative of orthopnea. In the terminal stage of mitral 
lesions there is often a peculiar listless rolling of the head from side to 
side which with the anasarca, blurred features, cyanosis and orthopnea 
makes a characteristic picture. In some cases of aneurism, acute- 
aortitis or malignant growth involving the mediastinum,* the patient 
not only sits up but must lean forward so as to rest the head upon the 
knees or upon some special support provided. In a case of Hodgkin's 
disease coming under the author's observation this attitude was as- 
sumed for weeks before the patient's death. So also in diaphragmatic 
pleurisy the patient sometimes sits inclined towards the affected 
side. Most careful attention should be given to the attitude of 
an unconscious patient with particular reference to paralysis, often- 



Transient 

or fixed ? 



Appendici- 
tis and peri- 
tonitis. 



Pleurisy. 



Meningitis. 



Scorbutus 

and 

rachitis. 



Asthma 
and heart 
disease. 



Aneurism. 



Mediastini- 
tis aortitis. 



Diaphrag- 
matic 
pleurisy. 



Paralysis. 



*The same attitude may be assumed occasionally in extreme incompens- 
ation and asthmatic seizure. 



THE OUTWARD SIGNS OF DISEASE. 



35 



times the appearance and passivity of an affected member or side is 
characteristic. 

GAIT. — When practicable the legs should be uncovered from the 
hips down and in women the nightdress or chemise may be brought 
forward between the legs and fastened above so as to permit free obser- 
vation and movement. The patient should walk briskly and then 
slowly, with the eyes open and shut, stop and turn sharply at command, 
and follow a rug border or crack at right angles to the line of vision. 
Due allowance must be made for nervousness and careful watch be 
kept lest a serious fall occur in some ataxic patient. The ordinary 
limping gait is to be referred to its proper cause, i.e., acute or chronic joint 
disease, flat foot, corns, etc. A tilting forward of the body is noticeable 
in paralysis agitans, kyphosis due to vertebral caries, and certain painful 
abdominal affections both acute and chronic. Leaning backward or 
an actual lordosis may be due to spinal disease, advanced pregnancy, 
abdominal tumors, ascites or obesity and is an important symptom of 
pseudo -hypertrophic paralysis and cretinism. 

The gait of the ataxic stage of locomotor ataxia is striking, the feet 
being raised suddenly, jerked uncertainly forward beyond the ordinary 
limit and brought down heel first with a stamp. The patient keeps them 
well apart and must keep his eyes upon the ground, lest he sway or 
even fall. A sudden turning movement or an abrupt rise from the sit- 
ting posture is to him difficult or impossible. It must not be forgotton 
that a patient may have the disease for years before this typical gait 
appears, but even in such cases the acute observer may detect some of 
the peculiar features. In marked contrast is the spastic gait character- 
istic of hemiplegia if unilateral, of lateral sclerosis if bilateral. The rigid 
leg moves stiffly, the foot does not quite clear the ground, necessitating 
a tilting of the pelvis at each step, the toes describing an arc ("mowing 
gait") and wearing down the sole on its inner side. Spastic contraction 
of the adductors sometimes produces a u cross legged progression" also 
seen in hysteria. The steppage gait is most often seen in multiple 
neuritis as a result of foot drop, because of which the patient must 
lift the foot to raise the toe clear of the ground and the result is a paw- 
ing movement, the patient appearing to step over constantly recurring 
though non-existent obstacles. 

The Choreic Gait.— When present is that of the school boy, who 
in the schoolroom intentionally trips over his heel to attract the attention 
of his fellows. It is seldom unassociated with other characteristic 
symptoms. The reeling gait of cerebellar (vermis) lesions differs in no 



Necessary 
man- 
oeuvres. 



Limping. 



Paralysis 
agitans. 



Leaning 
backward. 



Tabes 
dorsalis. 



Mowing 
gait. 

Cross- 
legged. 

Prancing 
gait. 



Titubating 
gait 



yj 



3« 



MEDICAL DIAGNOSIS. 



Waddling 

gait. 



Festinant 
gait. 



Erb's 

dysbasia. 



Myotonia. 



A bastard 
syndrome. 



Hysteric or 
neuras- 
thenic. 



Obesity. 



Early 
weight loss 



Wasting. 



Lax skin. 



respect from that of a drunken man. The waddling gait of pseudo- 
hypertrophic paralysis is due to the weakness of the glutei muscles. 
The pelvis and head of the femur are jerked forward at each step, the 
flexed knee is advanced, extended only after the foot is placed flat 
upon the ground, and the patient cannot stand on tiptoe. The festinant 
gait is pathognomonic of paralysis agitans and the patient walking as 
if trying to recover from a thrust from behind, trotting or shuffling 
with the body bent forward. 

Intermittent claudication and Thomsen's disease merit special 
reference. The former is associated with arterio-sclerosis and deficient 
circulation in the lower limbs, characterized by numbness or painful 
cramps on standing and walking, associated with rigidity, paresthesia or 
disability, often entirely absent when at rest. The latter, a family disease, 
is characterized by stiffness or painless contraction on attempting any 
muscular action. This in walking at first checks or delays each step 
but gradually wears away and permits normal progression, only to 
re-appear when any new muscle group is called into action or the same 
action repeated after a rest. In the former disease the pulse is usually 
absent below the knee during the seizure. 

Astasia. — (Inability to stand). Abasia. — (Inability to walk). This 
must be classed as a functional neurosis inasmuch as all other nervous 
functions are normal and the picture strongly suggests hysteria. Walk- 
ing may be impossible yet all its movements may be normally per- 
formed when the patient is lying in bed. The inability may be absolute 
or partial, giving rise to what simulates spastic paralysis on the one hand 
or flaccidity upon the other. Saltatory spasm is sometimes observed. 

WEIGHT AND HEIGHT.— Every doctor's office should contain a 
pair of accurate scales, and a knowledge of the weight, past and present, 
! is of the utmost importance both in diagnosis, prognosis and treatment. 
In general one encounters a tendency to increase in weight after the 
age of 40 and corpulence is ordinarily associated with a weak muscu- 
lature, poor resistance to acute disease and a decided tendency to degen- 
eration of the heart, blood vessels and kidneys in middle age. Early- 
loss of weight is one of the most significant signs of incipient tuber- 
culosis and carcinoma of the stomach as well as many other chronic 
ailments. Wasting or emaciation is pronounced in certain digestive 
disorders, all severe or prolonged fevers, true diabetes mellitus and 
the various wasting diseases of children. .4 very fair estimate of weight 
loss can be made by pinching up a fold of the skin over the upper arm 
and noting its looseness. In chronic exhausting diseases not only is 



THE OUTWARD SIGNS OF DISEASE. 



37 



Edema. 



the skin a misfit but it lacks normal elasticity. Increase of 
ordinarily indicates an improved general condition and the arrest of 
any local disorder, but it must be remembered that edema also increases 
it, and in Bright's disease especially, the variation in body weight 
may reveal a hydremia not shown by outward signs. So also loss of 
weight may in this and in cardiac types of edema be a most favorable 
symptom. Weight loss always accompanies profuse diuresis, sweating 
or purging. Children should be weighed weekly and should show an infants. 
increase of from 20-25 grams each month for the first four, from 12-20 
grams for the five succeeding and somewhat less for the remaining 
months of the first year of life. During the first days after birth they 
may show a considerable weight loss. Weighing should be done at 
the same hour in relation to meals in all cases and with the same amount 
of clothing if possible inasmuch as the estimate of five to seven pounds 
(for clothed adults) usually made is subject to grave error. The relation 
of height to weight is important and is well shown in the table which 
appears upon the opposite page. This was prepared by Dr. O. H. Rogers 
and is ingenious and accurate. Insurance companies regard with sus- 
picion men whose weight runs more than 20 or 25% above the standard 
as indicated by the table and that this prejudice is well founded has been 
shown by the results of the recent combined actuarial investigation 
which has proven a high mortality in this class of lives. The table of 

FOR AGE FORTY-SEVEN AND UPWARD. 



Precau- 
tions. 



Height and 
weight. 



Life 
insurance. 



Height. 



feet. 



1 inch 

2 inches.. 

3 " •• 

4 " •• 

5 " •• 

6 " ... 

7 " •• 

8 " 

9 " •• 

10 " 

11 " 



1 inch ... 

2 inches. 



Normal 
Weight. 

134 pounds. 
136 « 

138 " 

141 
144 

148 " 
152 

157 " 
162 
.67 « 

[ 7 2 « 

I 78 " 

[83 " 

1 88 

H)| 

200 " 



-20 Per 
Cent. 



107 pounds. 

109 " 

no " 

113 " 

115 " 

118 " 

122 " 

126 " 

130 « 

c 3 8 " 

\.\2 

146 » 

150 " 

155 " 

l6o " 



+ 20 Per 

Cent. 



161 pounds. 

163 
166 
169 

173 
178 
[82 
[88 

,0, 
200 
206 
a 1 4 
220 
226 

233 

240 



Foi 

the res 



+ 30 Per 
Cent. 



174 pounds. 

177 " 

179 " 

183 « 

187 « 

192 " 

198 " 

204 ' 

211 " 

217 " 

224 " 

2 3 ] " 

238 " 

244 " 



*5 a 
260 



• younger ages subtract i pound for each year un 
It will be the normal weight for the given age. 



ler forty -seven, and 



i 



s* 






3« 



MEDICAL DIAGNOSIS. 



D. H. Wells is also given and is an excellent one for practical use. 
In connection with underweights a family history of tuberculosis or 
personal history of past infection, a narrow chest, small heart and the 
evidence of poor circulation are extremely important. So also in 
overweight one must distinguish between those who have big bones, 
firm well developed muscles and moderate abdominal girth as compared 
with the flabby, big bellied sedentary livers and heavy eaters, partic- 
ularly if these have a family history indicating an hereditary tendency 
to apoplexy and diseases of the heart and kidneys. Very tall, slender 
men, giants and professional athletes are not as a class long lived. 



Under- 
weight, sig- 
nificance. 



Over- 
weight. 



Age 

estimation. 



Apparent 

vs. 
Actual. 



Diseases of 
infancy and 
youth. 



Middleage. 



Old age. 



Rapid 
aging. 



AGE— SEX— HABITS— SOCIAL STATE AND RESIDENCE. 

AGE. — By practice and close observation one can usually estimate 
closely the age of patients, though like the census enumerator he may 
at times in the case of women be obliged to accept statements with a 
mental reservation. The essential points are apparent as compared 
with actual age and unduly rapid aging. Certain ages represent a special 
predisposition to certain diseases, acute and chronic. In infancy and 
childhood we meet especially with acute digestive disturbances, rickets, 
the exanthemata, affections of the lymph glands, meningitis, infantile 
palsies, chorea, croup and cretinism. Tuberculosis attacks the young 
with an especial frequency and a higher mortality, but in those under 
the age of puberty it is peculiarly liable to affect the lymph glands, 
particularly those of the cervical triangles or abdomen. During adoles- 
cence, chlorosis, various forms of hysteria, epilepsy, acute rheumatism, 
gastric ulcer and tuberculosis are extremely common. As middle age 
approaches the tendency to the exanthemata and to acute infections 
generally is diminished and a predisposition to degenerative diseases of a 
chronic type appears. Such are arterio -sclerosis, myocarditis, valvular 
diseases, gout, gall stones, diabetes, the insanities, various forms of 
paralysis, profound blood disturbances such as leukaemia and pernicious 
anaemia, carcinoma, chronic Bright's disease and asthma. In old 
age, this predisposition of middle age is, in certain conditions, intensi- 
fied and in addition we find prostatic disease, chronic bronchitis and 
emphysema, and a return to the childish tendency to broncho-pneu- 
monia. In some instances diseases are wholly limited to certain age 
periods, but usually in weighing diagnostic probabilities the question is 
one of relative frequency. For example, cancer of the stomach is as 
rare in a person under 20 as is mumps in one over 70. Rapid aging may 
bring the man of 30 to the same status as the one of 70, and on the 



AGE — SEX— HABITS — SOCIAL STATE AND RESIDENCE. 



39 



other hand, the latter, by reason of inherited vigor of constitution and 
right living may be physically 20 years under his actual age. Every 
clinician repeatedly encounters cases of marked arterio-sclerosis in men 
under 30 years of age. The inheritance of poor structural material, dis- 
sipation, and mental strain are the chief factors in early aging. Finally, 
one must remember the effect of age upon prognosis. The acute exan- 
themata though more readily acquired are for the most part much more 
lightly borne by the child than by the adult and resistance to tuberculosis 
is much more marked in persons above the age of 30. Pneumonias 
are peculiarly fatal at the extremes of life and the young old people 
strongly resist the advance of chronic disease. 

SEX. — In general, men and women suffer about equally and resist 
in about the same measure the larger number of diseases, nevertheless 
there are certain striking differences both as to incidence and severity. 
As compared with men, women, through the disabilities peculiar to 
their sex, appear to develop superior endurance particularly marked 
in chronic disease. The woman is especially liable to neurasthenia, 
hysteria, movable kidney, myxcedema, arthritis deformans, chlorosis 
and chronic secondary anaemias, gall stones, goitre, cancer of the breast, 
and gastric ulcer. On the other hand, she almost escapes haemophilia, 
aneurism and locomotor ataxia, and suffers less often than the man 
from acute infections, gout, appendicitis, typhoid fever, certain diseases 
of the heart, progressive muscular atrophy, diabetes, carcinoma of 
the stomach and bowel, leukaemia, pernicious anaemia and Addison's 
disease. 

Race. — The special predisposition of the Hebrew to diabetes mellitus, 
of the Irish to tuberculosis, of the English to gout, of the continental 
races to suicide, etc., etc., is well known. Moreover certain races show 
markedly greater resistance to disease and surgical procedures than 
do others. 

HABITS AND ENVIRONMENT.— The term "habits" should 
cover a much larger field than the patient's indulgence in tobacco, 
drugs, or alcoholics and include his environment and mode of life, his 
hours for meals and for sleep, his manner of eating and the nature 
of his meals, no less than the extent of his drinking. One should ask 
specifically what was taken for breakfast or lunch preceding the time 
of the examination, or just what is usually taken at such a time, how- 
much water is drunk and when, how much time is taken for the meal. 
whether the food is properly masticated, and indeed ascertain the con- 
dition of the teeth by direct inspection when examining the tongue and 



Young old, 
and old 
young men. 



Age affects 
prognosis. 



Predispo- 
sition. 



Immunity, 



*cope. 



Specific 
inquiry. 



A 



40 



MEDICAL DIAGNOSIS. 



Tea, 

coffee and 
tobacco. 



Its dan- 
gers. 



Misuse of 
terms. 



^hroat. The author believes that too much stress is laid upon the use 
of tea, coffee and tobacco, and too little upon the idiosyncrasy of the 
patient in regard to these articles. That which constitutes excess for 
one represents moderation in another and the slight amount representing 
the average consumption can ordinarily be of little consequence; hence 
it is a positive hardship to arbitrarily shut off rather than to sensibly 
cut down the tea, coffee or tobacco which for years has been the solace 
of some elderly patient. As regards tobacco, especially, one may say 
that the signs of overindulgence are found in unrefreshing sleep, furred 
tongue and bad taste in the mouth, nervousness which takes the form 
of mental irritation and perhaps tremor, and at times a distinct disturb- 
ance of digestion and irritability or palpitation of the heart. In the 
man under middle age these symptoms mean little; in the elderly man 
much, and for the latter, persistence in excess is fraught with danger. 

The Use of Alcohol. — The common mistake of the novice is a failure 
to bring out tactfully yet fully the facts bearing upon a patient's alcoholic 
indulgence. He is too easily satisfied when the patient says he "does 
not drink at all," or he "takes an occasional drink," or "not enough 
to hurt him," "a drop now and then," "just a social glass," etc., etc. An 
absolute denial of overindulgence is usually proudly made by the man 
who has been a hard drinker for years but has stopped, it may be 
only for a few days. The "now and then" kind, or those who say 
"often not for a year," frequently represent the worse type of spree 
drinkers. One should inquire therefore about the present and the past, 
the extent, the hours, the kind, in what relation to meals and with what 
affect upon the health. It is impossible to lay down an absolute rule 
as to what constitutes excess and it is probable that the man who takes 
a little liquor, even two or three times a day well diluted and on a full 
stomach, may suffer little or no bad effects, but the American style of 
drinking is peculiarly harmful, as taking the form of "cocktails" before 
meals, and a pernicious multiplicity engendered by the custom of 
"treating." The three diseases most often due to such overindulgence 
are : — delirium tremens, alcoholic neuritis, and cirrhosis of the liver, but 
it is a powerful contributory factor in an enormous number of chronic 
diseases, inviting and promoting their development and shortening 
life and in severe acute diseases such as pneumonia the drunkard 
i stands little show. 

Drug Habit. — As regards the use of drugs, we have chiefly to deal 
with the various forms of opium and with cocaine. Neither produces 
in every individual a clear and definite syndrome but one of the pri- 



Excess. 



Diseases 
induced. 



Resistance 
to disease. 



Opium and 
cocaine. 



AGE — SEX — HABITS — SOCIAL STATE AND RESIDENCE. 



41 



mary indications is a peculiar nervous instability, or a baffling and 
bastard symptom complex. A markedly dilated pupil in cocaine 
users or a markedly contracted one in the victim of the opium habit 
may attract attention, but in either at the time of examination the pupil 
may be normal. If one examines such patients thoroughly, he will 
often find recent hypodermic punctures, black dots representing old 
ones or evidence of recent or old multiple abscesses due to the use of 
dirty needles. Such are usually on the right thigh or left arm of a 
right handed person, and the needle is usually introduced directly through 
the clothing. The peculiar pallor sometimes present has been referred 
to, the skin is likely to be dry in morphine users, the appetite poor and 
bowels constipated and the victims of either drug are subject to fits 
of profound depression succeeded by periods of buoyancy. "Nose 
rubbing" may suggest opium and in the case of cocaine users especially 
formication is not an infrequent symptom. The excessive use of cocaine 
may be honestly denied by one who has contracted the habit through 
the use of the drug in the nasal passage or throat, and the author has 
encountered many such cases, the patient not realizing that absorption 
takes place in such instances as readily as if the drug were actually 
taken into the stomach. The overuse of such drugs as acetanilid may 
become a fixed habit and lead to serious or even fatal illness. 

MARRIED OR SINGLE.— The question of marriage is important 
chiefly in relation to the matter of pregnancy or childbearing in women 
and its after effects. Many obscure ailments in the female are traceable 
to unrecognized or neglected lacerations, while endometritis, uterine 
displacements, pelvic abscess and epithelioma are especially common 
in multiparas. The number of pregnancies, the duration and severity 
of labor, miscarriages and the circumstances attending them, the 
number of children living and dead, the health of survivors and the 
causes of death of those deceased, are important. Marks of syphilis 
in a child should at once direct attention to one or both parents and 
vice versa, and tuberculosis and other diseases may be suggested in a 
similar manner. 

OCCUPATION. — The occupation and environment are important 
factors in diagnosis and prognosis and may throw light upon degener- 
ative processes, functional and organic nervous disease and accidents. 
City dwellers and indoor workers suffer especially from dyspepsia, tuber- 
culosis, neurasthenia and similar disorders. On the other hand, even 
the country dweller ami out of door worker may suffer from the poor 
ventilation and deficient sanitation to be noted in manv farm houses. 



Difficulties 
encount- 
ered. 



Hypoder- 
mic marks. 



Mental 
state. 



Innocent 
victims. 



Acetanilid. 



Pregnancy 
and child- 
birth. 



Miscar- 
riages. 



Sedentary 

vs. 
Aeti\ e. 



(. itv 

Country. 



Exposure. 



42 



MEDICAL DIAGNOSIS. 



Fatigue 
neuroses. 



House- 
maid's 
knee. 



School 
girls. 



So also must one consider the effect of unusual exposure to cold, wet, 
and to such poisons as malaria. The best conditions are to be found 
in camp life or the homes of the better class of agriculturists, the worst 
in the slums, sweat shops or improperly ventilated factories of great 
cities. On the one hand there is the maximum of fresh air, sunshine 
and healthful exercise, on the other foul air in the shop and home, 
constant exercise of the same muscles and in cramped positions, and 
as a rule deficient or improper food. Certain occupations involving 
the continuous use of one neuro-muscular unit produce specific ailments 
as do those involving pressure, or irritation of a particular portion of 
the body. Cases of nystagmus have been reported as due to the cramped 
position of miners working with eyes fixed upon a particular point. 
Penman's cramp or scrivener's palsy is a familiar example, and the 
chronic laryngitis of military men, clergymen, auctioneers and public 
speakers falls under the same head. Another example is the inflamma- 
tion of the patellar bursa, known as "housemaid's knee," the condition 
being encountered also in roof shinglers, tile layers and others working 
under similar conditions. 

"Going to boarding school" is one of the worst of occupations if 
the school work is over-hard, the heating and ventilation insufficient, 
the food poorly prepared or lacking in quality and variety or the out 
of door exercise scant. Nothing breeds more chlorotics than a poor 
boarding school or makes healthier women than does a good one. 

Habits in Relation to Occupation. — The excessive use of intox- 
icants is definitely related to certain callings. The manager of a large 
hotel syndicate has said that he has yet to see one bar-keeper who 
failed to develop the drinking habit, and this statement undoubtedly 
expresses a rule subject to few exceptions. A traveling man who 
sells bar supplies, cigars, or even mineral waters is constantly subjected 
to a pressure which too often results in the formation of the liquor 
habit. 

Occupation Involving Continuous Mental Strain. — In this day 
of great enterprises a large proportion of the chronic ailments encount- 
ered by the physician may be traced in whole or in part to continuous 
mental over-strain, usually combined with lack of exercise, improper 
diet and too often with over-indulgence in liquor or tobacco. No one 
who has seen the remarkable improvement in chronic disorders of the 
heart, stomach, kidneys, or various diseases of the nervous system, that 
follows a period of complete rest and freedom from worry, can doubt 
the potency of nervous strain as a factor in the etiology and prognosis 



Barkeepers 
and the 
like. 



Combined 
factors. 



Potency of 

nervous 

strain. 



OCCUPATION. 



43 



The 
physician. 



of disease. Railroad men, financiers and especially board of trade 
operators suffer greatly from this cause. The life of a practising phys- 
ician is of such a nature as to readily explain the high early mortality 
encountered in this class, for in the physician's calling are combined 
deficient and interrupted sleep, lack of exercise and recreation, excessive 
and continuous mental strain, and a large demand upon the kindly 
emotions so constantly appealed to by his clients. 

Mineral Poisoning. — A complete volume would be required to do 
justice to this aspect of our topic, and there can be no doubt that too 
little attention is paid to the possibility of occupational poisoning by 
physicians other than those practising in large manufacturing centres, 
where the conditions are exceptionally favorable to the development 
of occupational diseases. 

Arsenic. — Aside from poisoning due to the inhalation of fumes or 
dust during the processes of milling, grinding and smelting one encount- 
ers cases amongst workers in aniline dyes, toy or artificial flower makers, 
dyers of woolen or cotton goods, playing card makers, taxidermists, 
lithographers and shot makers. 

Aniline. — This derives its harmful effect from three sources viz. : — 
itself, the arsenic often combined with it, and the nitro-benzol used in 
its manufacture. 

Bromine and Iodine. — The fumes of this substance cause bron- 
chitis and predispose to tuberculosis. 

Carbon Bisulphide. — This highly poisonous substance is used as a 
solvent for sulphur, iodine and oils and is largely used in the manu- 
facture of rubber goods. 

Chlorine. — In the bleaching of linen, cotton, bones, ivory and rags 
the fumes are irritating to the bronchial-mucous membranes and 
predispose to tuberculosis. 

Chromium. — This enters into chrome yellow and chrome green, 
and is used in staining glass or porcelain, printing bank notes, and 
dyeing linen, wool and silk, and as potassium bichromate is used in 
photography. 

Copper. — Workers in brass, nickel platers, bronzers, copper shoot 
scrapers, pin makers, bell metal workers, stone workers, engine wipers, 
and others handling copper, bronze, brass or nickel may suffer from 
chronic poisoning. It should be remembered that brass is composed 
of copper and zinc, with or without tin and load, bronze, of all four 
metals, and that nickel plating is sometimes done with an alloy composed 
of copper, nickel, iron and tin. It is further combined oftentimes 



Workers 
affected. 



Composi- 
tion. 



44 



MEDICAL DIAGNOSIS. 



Often over- 
looked. 

Suggestive 
occupa- 
tions. 



Tubercu- 
losis. 



Sepsis, 

tetanus, 

glanders. 



Suicide. 



The 

lowered 
shoulder. 

Crippled 
hands. 



with lead and arsenic. One of the most severe cases of lead poisoning 
ever encountered by the author was caused by polishing an alloy of 
this kind. 

Lead. — The possibility of lead poisoning in obscure gastro-intestinal 
affections as in connection with its well known nervous manifestations 
should never be forgotten. Not only is it found in lead smelters, refiners, 
sheet-lead rollers, lead pipe makers, shot makers, type-setters, plumbers, 
toy makers, and painters, but also in lacquer polishers, gilders, bronzers, 
enamel workers, glaziers, all pot, pan, card, cardboard or brick makers, 
makers of brass instruments, file cutters, flint glass workers, workers 
in white or red lead and litharge, calico printers and those engaged in 
the manufacture of lace, artificial flowers and- wall papers. 

Mercury.— Chronic mercurial poisoning may result from idiosyncrasy, 
long continued over-dosage, or employment in smelters, quick silver 
mines and felting rooms. 

Phosphorus. — This is now comparatively rare, and is almost wholly 
limited to those engaged in the manufacture of the parlor match. 

Turpentine. — Some persons are peculiarly subject to turpentine 
poisoning, and painters working in poorly ventilated rooms may become 
chronically affected. 

Occupations Involving Excessive Heat. — Extreme dry heat can 
be borne without serious results in persons habituated, nevertheless, fire- 
men on ocean steamers or naval vessels, and bakers suffer from heat, 
moisture, foul air, and the effects of chill and exposure due to extreme 
temperature variations. 

Miscellaneous Diseases of Occupation. — Millers, potters, file 
cutters, grinders of edged tools, wool and cotton spinners, marble and 
stone cutters are peculiarly susceptible to tuberculosis, particularly in its 
fibroid form. Handlers of rags and skins occasionally acquire anthrax, 
internal or external. Female domestics are peculiarly liable to anaemia, 
gastric ulcer and tuberculosis. Butchers or slaughter house men suffer 
from septic infections, stablemen from tetanus and glanders, brewers, 
saloon-keepers, bar-tenders and others of the same class show an 
enormous mortality from alcoholism, tuberculosis, diseases of the nervous 
system, pneumonia, diseases of the liver and kidneys, and suicide. 

Occupational Stigmata. — Those who follow certain occupations 
often present somewhat characteristic deformities; the lowered shoulder 
of the desk worker, pack peddler and tailor are familiar to everyone. 
Few railroad trainmen escape for long without the loss of one or more 
fingers. 



OCCUPATION AND RESIDENCE. 



45 



Furthermore, the study of the callosities associated with certain 
callings may at times prove helpful both in diagnosis and identifica- 
tion, and a few of the occupations thus suggested are briefly given 
below. 

Banjo, Guitar and Harp Players. — Finger tips both hands. 
Zither Player. — Finger tips of left hand, under surface and tips of 
index, middle and ring ringer of right. Violincello or Violin 
Player. — Tips of fingers, left hand only. Compositors. — Palmar sur- 
face of thumb and index finger, right hand. Fencing Masters. — 
Ulnar border, right palm. Hand-organ Man. — Outer side of right 
hip and thigh. Seamstresses. — Roughened radial border of terminal 
phalanges of left thumb and index. Tailors. — Ring shaped callous on 
right thumb and index finger, left thumb and index roughened, enlarged 
bursas over external malleoli. Turners. — Outer border of right little 
finger. Clerk Using Pen or Pencil. — Outer surface of terminal joint, 
right little finger. The Rough Callous Hand of the day laborer 
contrasts sharply with the soft hand of the sedentary worker, as does 
that of the seamstress or domestic with those representing the lighter 
occupations of her sex. The tan of the sailor contrasts sharply with 
that of the soldier, the one wearing his shirt open at the front, the other 
the high collar. 

General Comment. — Want of occupation is often deleterious and 
the neurasthenia and hysteria, morbid irritability and ennui of a certain 
class of women are rarely seen in the hardworking housewife. The man 
who for years has given his attention to active business or professional 
work may find complete idleness both boresome and dangerous and few 
men or women can be well mentally or physically without some definite 
occupation, and every man who in later years forsakes his life's work 
should cultivate a hobby or divert himself by travel. 

RESIDENCE. — The novice frequently fails to secure the full namd 
and postal address of the patient under examination, forgetting that 
future communication is sometimes most important in that some of 
the most valuable information comes from the following up of unusual 
cases. Both present and past residence should be known, and, in 
general, information upon this subject is of value in relation to the 
possible introduction of epidemic disease by persons coming from an 
infected area, in tracing its distribution, as in an epidemic of cholera or 
typhoid affecting certain portions of a city or Larger district, in tracing 
its individual sources as illustrated by the detection of careless 
dairymen, who spread infection along their route, and finally, because 



Callosities. 



Idleness a 

disease 

breeder. 



Value of a 
" hobby." 



Record 

important. 



Present 
and past. 

Epidemic 



A 



46 



MEDICAL DIAGNOSIS. 



The home. 



Inherited 
predispo- 
sition. 



Specific 
inquiry. 



Blind 
terms. 



Direct 
transmis- 
sion rare. 



Short vs. 
long-lived 
families. 



of the special liability to certain diseases in definite districts or countries, 
as illustrated by the diseases of the tropics, such as malarial fever, 
dengue, yellow fever, and plague, the hydatid disease of the Icelander, 
or the leprosy of the Sandwich Islander. Specific inquiry concerning 
the exact situation of the patient's house, its elevation, exposure, the 
character of the surrounding soil, and the location of the sleeping 
chamber, is often important. 

FAMILY HISTORY. — The transmission of special structural vul- 
nerability and predisposition is just as marked and as well proven as 
inherited likeness in form or feature, and in taking a family history, 
one should secure full information as to the terminal illnesses of family 
members, often going back two generations and including collaterals, 
and of the state of health or cause of death of the husband or wife of 
the patient, and the children. It is seldom sufficient to ask whether 
any members of the family, immediate or remote, have suffered from 
hereditary disease, or even to put the question in the somewhat more 
specific form of an inquiry concerning tuberculosis or cancer. Apoplexy, 
heart disease or Bright's disease may be readily admitted, but insanity, 
epilepsy, tuberculosis, and malignant disease are often concealed, 
either intentionally or innocently. The questions must bring out the 
symptoms of the illnesses of family members. One may ask if there 
has been chronic cough, spitting of blood, emaciation, night sweats or 
fever in a given case, or the vomiting of blood, or the presence of a tumor, 
associated with emaciation and failing strength. Deaths from " child- 
birth," "exhaustion," "grief," " broken heart," "general decline," etc., 
must never be accepted without careful and tactful cross examination. 
"Senility" or "old age" are much abused terms and in the lay mind 
may cover death at any age above 50. No man ever passed his novitiate 
as a case-taker, without saying hard things of "malaria," "chills," 
"fever," "decline," and especially "marasmus" and "don't know," 
and no student can give better evidence of his skill and tact than is 
furnished by a full and complete family history. 

Alternatives in Heredity. — Few diseases are directly transmitted 
as such; rather does hereditary influence take the form of predisposition. 
Thus the disease of the descendant may be but the congener of that 
of the forbear and as such is termed an alternative, or, the inheritance 
may be that of marked vulnerability or its opposite, invulnerability. 
To the former class belongs the "short lived family," whose members 
show a low average life time and a ready acquirement of and feeble 
resistance to acute or chronic ailments. To the latter appertains a 



: 



FAMILY HISTORY. 



47 



Alterna- 
tives in 
nervous 
diseases. 



Cardio- vas- 
cular alter- 
natives. 



Distinctly 
hereditary. 



vigor of constitution and strength and harmony of structure which 
ensures resistance to disease and long life. 

The Nervous System in Heredity. — A strong alternative relation 
exists between alcoholism, insanity, epilepsy, hysteria and criminal 
impulse. In some families, however, there is little variation, insane 
grandchildren follow insane grandparents, epilepsy in the father means 
the same disease in the child, and some remarkable cases of hereditary 
alcoholism have come under the author's observation. In one especi- 
ally it seemed impossible for any family member to escape the curse. 

Apoplexy. — The hereditary tendency to cerebral hemorrhage is one 
of the most striking facts in medicine and is inseparable from its alter- 
native conditions, arterio-sclerosis, chronic Bright's disease, aneurism 
and the degenerative diseases of the heart. The author has reported 
a case in which, of nine family members, five died of apoplexy, two of 
chronic Bright's disease, and one of heart disease, every death occurring 
between the ages of 40 and 55. The then surviving brother has since 
died of the dominant disease. 

Cancer. — Few physicians of experience will be found who deny the 
hereditary nature of cancer, yet it is well to avoid too radical statements 
in regard to it, as tending to create undue apprehension in the minds 
of members of tainted families. Like apoplexy the tendency in this 
disease is towards death in middle age, the transmission seeming to 
be more marked from mother to daughter than from father to son. 

Diabetes. — Few diseases are more distinctly hereditary than diabetes, 
if we regard it as one of the alternatives of inheritance in nervous and 
mental diseases. According to recent observers it is possible to separate 
a distinctly hereditary form which is characterized by an equality in 
predisposition as between male and female, or even to predominance 
in the female. The best examples of inherited disease are found in 
the race showing the greatest vulnerability, namely, the Hebrew.* 

Gout. — This distinctly hereditary ailment is potent in the production 
of arterio-sclerosis, apoplexy, Bright's disease, gastro-intestinal ailments 
and certain forms of diabetes, as well as all forms of gout. 

Haemophilia. — This extraordinary disease is atavistic in its trans- 
mission, the deadly tendency to excessive bleeding, spontaneous or 
induced, being transmitted through the females of a family to the 
male issue. In certain families it has been traced back for hundreds 
of years in unbroken -sequence. 



Race and 
heredity. 



Potent and 
protean. 



Atavistic. 



Females 

transmit. 



* The Hereditary Form of Diabetes. M. Loeb. Zentralblatt Fur Innere 
Medizin, Aug. 12, 1905. No. 32, page 786. 




48 



MEDICAL DIAGNOSIS. 



Direct 

transmis- 
sion rare. 



Diminished 
resistance. 



Deadly 
home sur- 
roundings. 



Nasophar- 
yngeal ob- 
struction. 



Life 

insurance. 



Degree of 

relation- 
ship. 

A source 
of error. 



Syphilis. — Direct inquiry is impossible and the physician must 
ordinarily depend upon the recognition of outward signs of inherited 
syphilis or in obscure cases apply the therapeutic test. 

Tuberculosis. — That in rare instances tuberculosis may be trans- 
mitted from mother to child in utero cannot be doubted and it is certain 
that the incidence of tuberculosis is greater in those of tainted family 
record. Inheritance probably has to do with structural and consti- 
tutional conditions which render the child of tuberculous parents 
or antecedents more vulnerable and less resistant to the tubercle bacillus 
than the one of sound, vigorous and untainted stock. Even predisposed 
children, if favored in climate and environment, need seldom or never 
develop the disease, under conditions eliminating the possibility of 
contact with the living germ, the exception being found in a latent 
prenatal glandular infection. Unfortunately, however, these victims 
of predisposition born into tuberculous households, are in every way 
exposed, through their stature, their creeping, their tendency to carry 
dirty hands and infected articles to the mouth, and even through the 
embraces of an infected parent, brother or sister. The peculiar shape 
of the chest associated with tuberculosis and found most frequently 
in those of tainted stock is merely one of the structural peculiarities 
and disabilities which become factors in infection and in the course 
of the disease. Far more important are obstructions in the naso- 
pharyngeal passages, especially adenoid growths and hypertrophied 
tonsils. These, in themselves favorable soil for the tubercle bacillus, 
by their interference with free respiration prevent the development of 
the lungs and actually retract the chest while further contributing to 
infection through frequent recurring colds and chronic catarrh. One 
has only to consult insurance manuals to understand how important 
are physique and family taint as factors in tuberculosis, and it may 
further be said that admitting certain exceptions it is generally true 
that an exceptional physique largely overbalances a bad family history. 

Special Conditions Affecting Heredity.— The significance of tuber- 
culosis in the parents is apparently but slightly greater than that in 
brothers or sisters, but probably this is because cases of arrested tuber- 
culosis in the parents are seldom to be traced in case-taking, such past 
events being usually either forgotten or concealed. Any one who 
has practised in a region frequented by cured consumptives will appre- 
ciate the truth of this statement. Physical Resemblance. — Mere 
facial resemblance is of little importance, but general structural likeness 
is distinctly so. Exposure to Infection. — The health of living family 



ANALYSIS OF CERTAIN COMMON SYMPTOMS. 



49 



members and especially of the children of parents under examination, 
as well as the condition of parents affected by or dying of tubercu- 
losis at the time of the birth of any individual under examination, are 
important. 

PREVIOUS ILLNESS.— A knowledge of the general state of health 
and past illnesses of a patient may assist the diagnosis, either by the ex- ' 
elusion of a disease of the permanent or temporary immunity-conferring immunity 
type, or by fitting a symptom group to the known after effects of a 
previous illness. The exanthemata and yellow fever illustrate the one, 
syphilis both. 

Misnamed Ailments. — A patient reporting "stomach trouble" 
may present a clear history of gastric ulcer, appendicitis or gall stones; 
another may have had repeated attacks of acute rheumatism or gout 
and our attention is thus directed to the heart, blood vessels, kidneys. 
A history of severe nocturnal headache may be explained by an ancient 
syphilis, or an intractable periodic neuralgia by past malaria. In such 
interrogation the simplest and most homely phraseology should be used, 
especially in dealing with the ignorant, and leading questions cannot 
wholly be avoided.* 



Use plain 
language. 



HISTORY OF "PRESENT AILMENT" AND ANALYSIS OF 
CERTAIN COMMON SYMPTOMS. 

History of Present Ailment. — The patient should tell of his own 
volition but in as few words as possible the symptoms of his disease 
and their duration. Any attempt to theorize or drag in immaterial 
facts should be tactfully checked. To guide and direct the disclosures, 
check verbosity and triviality and yet use few leading questions is an 
art both valuable and rare. One should discriminate between those 
symptoms that are general in their nature, common to a large number 
of diseases and subject to various interpretations from those that arc 
local, peculiar or specific. Some of the principal general symptoms 
will be described in this connection and only their special features 
referred to in other sections or under the symptomatology of specific 
ailments. 

FEVER. — Fever as a clinical manifestation is merely an elevation of 
the body temperature as formerly determined roughly In- the hand 



Check gar- 
rulity luit 
limit lead- 
ing ques- 
tions. 



Thermom- 

tin . 



* An ignorant patient of the author dying of previously unrecognized 
perforating duodenal ulcer readily admitted having formerly "puked* 1 Mood. 
though on repeated questioning he had denied "vomiting" of any kind. 



J 



5° 



MEDICAL DIAGNOSIS. 



Selectr 
points. 



Worthless 
thermom- 
eters. 



Prelimin- 
aries. 



Mouth tem- 
peratures. 



Axillary 
readings. 



Normal. 
Fever. 



Faulty 
statistics. 



but nowadays accurately by the clinical thermometer. In such dis- 
eases as pneumonia and typhoid the skin is dry and hot. On the other 
hand a high rectal temperature may exist in cholera and the surface 
temperature be as low as 70 degrees. The thermometer is ordinarily 
applied to one of four points, these being in the order of frequency, 
the mouth, the axilla, the rectum and the vagina. There is no poorer 
investment than a cheap clinical thermometer and the test scales 
supplied with some of those of the lower grades are worthless 
by reason of improper calibration, imperfect seasoning and misrepre- 
sentation on the part of the manufacturer. In the use of a thermom- 
eter, certain precautions must be observed: — 

(a). It should be cleaned before and after use. (b). The scale should 
invariably be inspected as the thermometers are self registering and 
require to be shaken down after use. (c). If used in the mouth, it 
should be placed well under the tongue and held by the tightly closed 
lips (not teeth) of the patient; if, for any reason the lips cannot be 
closed, if the patient be unconscious or delirious or if an acute stoma- 
titis or tonsillitis be present the temperature should be taken per rec- 
tum, or in the axilla, (d). Axillary temperatures should be avoided 
wherever possible, as being subject to greater error variation than in 
other regions. If so taken the thermometer should be placed deeply in 
the axilla which should have been freed from any moisture present and 
the elbow of that side should be close to the body and carried well 
forward. Axillary readings are particularly misleading in incipient or 
but slightly febrile tuberculosis. 

Temperature Range in the Human Body. — Our physiologists state 
that in normal persons the range may represent 99. 5 F. as a maxi- 
mum, and 97. 7 F. a minimum. Sub-febrile temperatures are those 
running from 99.5 to 101.3; moderate fever, ioi.3°-io3° F.; high fever, 
io3°-io5° F.; hyperpyrexia 105°+. There is a normal daily variation 
reflected in nearly all fevers, the range being about i° or 1.5 F., the 
lowest reading occurring in the early hours following midnight, the 
highest between 4 and 6 o'clock in the afternoon. Granting that 
99 F. to 99.5 or even 99. S may represent a normal variation in infants 
the author believes that the range as ordinarily given by the physiolo- 
gists for the adult is too high and based upon observations which included 
persons having incipient disease, such as pulmonary tuberculosis. 
Years of observation in private and public practice have convinced 

Note. — To convert Fahrenheit readings into centigrade multiply the 
centigrade reading by 9, divide by 5 and add 32. (See table, p. 643.) 



ANALYSIS OF CERTAIN COMMON SYMPTOMS — FEVER. 



51 



him that under ordinary clinical conditions, a persistent maximum 
temperature exceeding gg°F. is strongly suggestive of incipient tuber- 
culosis*, the onset of some acute ailment, or, at all events is referable to some 
pathological condition.^ By far the greater number prove to be cases 
of incipient tuberculosis, a condition recognized but rarely until within 
the last two decades. 

It should always be remembered that violent exercise and excessive 
heat slightly and temporarily raise body temperature and that in | 
infants and very old persons it may range half a degree or more higher 
than in those of intermediate age. The temperature of children more- 
over is easily affected and may reach a high degree without serious 
significance, often subsiding as suddenly as it came. For variable 
periods in certain cases of tuberculosis, acute or chronic, the morning 
temperature represents the maximum. 

Pathologic Variations in Temperature. — Hyperpyrexia of extra- 
ordinary degree has been reported, but has probably been due to deception 
on the part of the patient, it being a common trick of the malingerer 
or hysterjcal patient to heat the thermometer bulb by friction, by taking 
hot drinks just before the tube is applied or by utilizing a hot water bag. 
The highest temperature observed by the author was no under the 
tongue, and occurred in a woman of hysterical temperament suffering 
from spinal caries. Elevation of temperature may occur in hysteria, 
a fact never to be forgotten. The highest personally observed (104 F.) 
was obtained during an hysterical paroxysm following great emotional 
shock and the attack and the fever subsided almost instantly under 
sharp ovarian pressure. Some authorities claim that temperature 
may persist for weeks in hysteria and even simulate typhoid. + The 
significance of high readings is variable and certain hyperpyrexias seem 
to indicate little more than an intense infection associated with vigorous 
constitutional resisting power, such cases being seen in connection 
with lobar pneumonia, in which a temperature of 105 F. is neither 
uncommon nor necessarily of fatal import. Extremely high readings, 
if long sustained, indicate a most serious prognosis and a sudden rise 
sometimes precedes death. Subnormal temperatures may be observed 
in those suffering from collapse, chronic exhausting or wasting dis- 

* Many cases of chronic larval appendicitis yield similar temperatures. 
t A recent investigation of nurses' temperatures undertaken by the author 
in a local hospital has further strengthened this opinion. 

X Until we know more of the real nature of hysteria major and find fewer 

examples of its confusion with organic ailments it might be safer to assume 
that long continued fever excludes hysteria. 



Incipient 
tubercu- 
losis, etc. 



Heat and 
exercise. 



Ephemeral 
fever. 



Inverse 
tempera- 
ture. 



Malinger- 
ers. 



Hysteria. 



High fever. 



"' Agonal '" 
tempera- 
ture. 

Subnormal 

tempera- 

hires. 



J 



52 



MEDICAL DIAGNOSIS. 



eases, insanity (especially melancholia), chronic in compensated heart 
disease,* etc. Oftentimes the surface temperature is subnormal and the 
rectal high, notably in cholera and tuberculosis. 

Febrile Types. — Fortunately for the clinician, the fever in many 
of the acute diseases pursues a more or less characteristic course or 
bears a peculiar relation to the appearance of other symptoms of the 
disease. Fevers may be placed under three general heads: — 

i. Intermittent. 2. Remittent. 3. Continuous. 

An intermittent fever however far it may rise, 



Inter- 
mittent. 



Remittent. 



Continu- 
ous. 



Indeter- 
minate. 



Fastigium. 



Deferves- 
ence. 



drops to or below normal during some part of |jE!ii*§s 
the 24 hours (see fig. 5). A remittent fever 
shows marked remissions during the 24 hours; 
while in continuous fever the remissions are 
slight. These are but the types and one must 
understand that a continuous fever may at 
some stage show remissions, or a remittent fever 
encroach upon the intermittent; indeed the tem- 
perature charts covering long periods may in 
such diseases as tuberculosis show every type of 
fever and yet be predominantly intermittent. 
The intermittent fever of this disease is often 
given the name hectic. Roughly speaking one 
may say that when the maximum daily variation 
in a moderate or severe fever is less than 2 
degrees it is continuous, when more than 2 de- 
grees and yet with an average minimum dis- 
tinctly above the normal it is remittent; and 
that any fever showing a tendency to periodically 
fall to or below normal, is intermittent. The 
maximum stage of fever is known as its fas- 
tigium, the term being applied especially to the 
fevers of the continued or remittent type and to 
the disease as well as to the fever itself. Its opposite is called the 
period of defervescence or decline. 

Diagnostic Import of Fever. —Putting aside the rare cases of hys- 
terical temperature and excluding deception and faulty technique, one 
may say that fever is primarily of value in proving the existence of some 
organic ailment, a matter of no little importance in dealing with neuras- 

* A temperature under 90.5 F. was recently observed by the author in an 
ambulatory mitral case. 



I DAY OF 

DISEASE 


1 


2 3 


4 * 


6 


HOUR 


vl 


M U m| 


\ S w s 


P A P 


107 










































10G C 










































105 










































£ 104 










































B 

= 103 










































S 102° 








































p 

< 101° 










































s 10 ° 










































a 
99 




















































— 


tM' 


-+r 


~x 


98 


















97 










































96 





-f- 































Fig. 5. Clinical Chart 
of Ordinary or Tertian 
Malaria, showing three 
febrile paroxysms occur- 
ring on alternate days. 
Typical and extreme in- 
termittent temperature. 
1 From Wilcox's "Fever 
Nursing.") 



ANALYSTS OF CERTAIN COMMON SYMPTOMS — FEVER. 



53 



thenics and malingerers. Furthermore, save in children, it indicates 
infection or auto-intoxication, acute or chronic, or irritation of some 
portion of the central nervous system. The absence of fever however 
does not rule out any one of these conditions, for there is no disease 
ordinarily febrile that may not though in the rarest instances exist 
without fever or even with sub-normal temperature. It is best exempli- 
fied in the case of afebrile typhoid, occasional pneumonias, especially 
those of old age, and certain cases of general peritonitis. Fever seems to 
guage the reciprocal action of toxaemia, infection and individual resisting 
power. B y far the greater number of fevers are due to the action of j 
pathogenic germs and their toxines, yet many are due to other toxic 
substances or even those generated by the body itself as in the 




Afebrile 
cases. 



Measures 
toxaemia 
and resist- 
ance. 



Fig. 6. A Typhoid Fever Chart showing temperature typical and unmodified 
by treatment. (Rare.) It serves to illustrate the continuous and remittent type 
and lysis and shows the so-called "step-ladder" fever of the first week. (Wilcox). 

ptomaine poisoning due to the ingestion of deleterious food products 
and the curious auto-intoxication associated with deficient or faulty 
metabolism as illustrated by the terminal stages of diseases of nutri- 
tion, of malignant disease, gout, and certain of the severer types of 
anaemias. Fever of central origin may be encountered in cerebral 
embolism, thrombosis, apoplexy, brain tumor, and direct injury, or even 
by the changes incident to heat-exhaustion and sunstroke. Malnutrition 
is sometimes associated with fever, usually of a mild grade, which 
ordinarily occurs after severe exhausting ailments associated with much 
wasting of tissue and loss of strength.* 

Occurring under such conditions it is more likely to be due to a 



Autointox- 
ication- 



Cerebral. 



Nutri- 
tional. 



♦ The so-called 
valescent typhoids 



"hunger" temperature may be most misleading in con- 
who have been too long starved. 



J 



54 



MEDICAL DIAGNOSIS. 



smouldering tuberculosis or a complication, though it cannot be denied 
that cases of exhaustion temperature do occur. 



Consider 
onset type 
and cause. 



Dry and hot 



vs. 
moist. 



Aching 
head and 
legs. 



Mental 
condition. 



In children. 



THE PHENOMENA OF FEVER.— One must first determine 
whether the fever came on suddenly or gradually, whether it was asso- 
ciated with chill or in the child convulsions, for how long it has endured, 
whether it is to be classified as distinctly intermittent, remittent or con- 
tinuous, and furthermore, whether it is associated with any history of in- 
fection or with the appearance of an exanthem. If the latter be the case 
its exact time of appearance and 
its relation to any rise or fall in 
the temperature must be noted. 

Condition of the Skin. — In 
most fevers the skin is dry and 
palpably hot. Occasional cases 
depart from this rule and certain 
diseases such as acute rheuma- 
tism and cholera almost invari- 
ably violate it. 

Digestive Organs. — Nausea, 
vomiting or diarrhoea (initial, per- 
sistent or terminal), constipa- 
tion, loss of appetite and a 
coated tongue are present in 
varying degrees in all severe 
acute febrile ailments. 

The Nervous System.— 
Headache, and pain in the limbs 
are present in nearly all cases 
of fever, though often only at its 
onset. The mind may be clear 
or clouded and delirium may be present at the onset only, or for 
long periods, continuously or only at night. This may take the form 
of transitory illusions or hallucinations, may be violent and mani- 
acal, mild, or of the low muttering, mumbling type of the typhoid 
state, perhaps with open but unseeing eyes (coma vigil). Persistent 
delirium of the violent or low muttering type is of unfavorable prognostic 
significance. Children show an especial tendency to delirium even 
in fever of moderate intensity, whereas, it is rare in adults save in 
the most severe types of infection, in the intoxications or in central 
disturbances. 



OAY OF 

DISEASE 


1 


- 


3 


4 


5 


6 


; 


8 


9 


Id 


11 


12 


10 


HOUR 


- P 


V V 


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V M 


V V 


A F 


§ 


S ■ ■ 


A P 


A '- 


A F 


A P 


A F 


ior 




































































































































106 






- 






















































































































































































105 














































































•r 104 














































































































































£ 103 












































































































4- 














~" 102 













p^ 




zt 










































































a — 
g 101 












































































































































5 
g 100 




































































































































H 99 


















































































































































































































98 






















































97 




































































































































96' 

















































































Fig. 7. Clinical Chart of Measles show- 
ing defervescence by lysis beginning when 
the eruption is fully developed. (From 
Wilcox's "Fever Nursing.") 



ANALYSIS OF CERTAIN COMMON SYMPTOMS — FEVER. 



55 



3 

2 102 



lii; 



113 



vS 



Acute Febrile Delirium. — (Bell's mania). This rare condition pecu- 
liar to women and of unknown causation, is initiated by shock or other 
emotional strain, and may be associated with the convalescent state. 
It consists essentially of a violent, continuous, exhausting and maniacal 
delirium, associated with high fever and a typhoid state. No specific 

pathologic findings are present after 
death and the disease may readily be 
confounded with the acute maniacal 
delirium occasionally present at the 
onset of pneumonia, typhoid and urae- 
mia. It is rapidly fatal, running its 
course in from one to three weeks. The 
differential diagnosis is one of exclusion. 
The Pulse and Respiration. — Both 
pulse and respiration bear a definite 
relation to the temperature curve. The 
increase in pulse rate is ordinarily from 
8-i o beats for each degree of fever and 
a departure from this rule is especially 
noted in typhoid fever, yellow fever and 
lobar pneumonia, and favorably affects 
prognosis in these diseases. The heart 
muscle suffers to a variable degree in all 
infections and intoxications and must be 
carefully watched for signs of weakness, 
degeneration or valvular inflammation, 
this being especially true as regards the 
valves, heart muscle and pericardium in 
attacks of acute or subacute rheuma- 
tism and in diphtheria. The pulse of 
high fever of the so-called sthenic typo 
is not only rapid but full and bounding. 
In asthenic fevers it becomes soft, weak 
and in the typhoid state, dicrotic. In 
acute and chronic affections of the 
kidney it is of high tension and such a pulse should always direct 
attention to the kidneys, and calls for examination of the urine. In 
inflammation of the peritoneum it is small, hard, and wiry in Peel. 

Exanthems. — The accompanying charts show the peculiarities of 
fever in certain diseases. In measles the temperature recedes 24 hours 



E=iisjE 



Fig. 8. — Clinical Chart of a Yel- 
low Fever Patient showing the 
pulse typically slow in comparison 
to the height of the temperature. 
(From Wilcox's "Fever Nurs- 
ing.") 



Normal 
ratio. 



Typhoid 
and pneu- 
monia. 



Heart 
muscle. 



Sthenic 



Asthenic 
fevers. 



Renal 

pulse. 



A 



56 



MEDICAL DIAGNOSIS. 



Frank 
onset. 



Insidious 
onset. 



Senile 
cases. 



Lysis and 
crisis. 



or thereabouts after the onset, rising to reach its highest point with the 
coming of the rash on the fourth or fifth day. 

German Measles. — (Rotheln). In rotheln the eruption appears on 
the first day or more rarely the second, and is usually the first thing 
noted. The fever rising much the same but usually less than in measles. 

Scarlet Fever. — In scarlet fever the rapidly spreading rash appears 
on the first or beginning of the second day following an abrupt onset 
with high fever. 

Varicella. — (Chickenpox). In varicella the rash appears within 24 
or 36 hours associated with trifling fever. 

Variola — (Smallpox). In variola 
the violent onset, usually with chill and 
high fever is followed by a marked 
remission during which the rash ap- 
pears in its papillary stage. During 
its subsequent changes the tempera- 
ture rises, reaches its maximum with 
the purulent transformation of the 
vesicles and then gradually sub- 
sides. The diagnostic value of these 
differences in the relation of body tem- 
perature to the eruption is readily 
appreciated. 

The Mode of Onset and Termi- 
nation. — The more severe of the acute 
infections are usually preceded by a 
decided " chilliness" or an actual chill 
in adults* and in children by either 
chilling or convulsions. In several 
diseases however the onset is insidious 
and without marked initial phenomena and in senile cases this may be 
true of ailments ordinarily frank. The termination of fever is in most 
cases a gradual recession (lysis) but certain ailments of which lobar 
pneumonia is the type terminate suddenly (crisis) . The critical phe- 
nomena vary somewhat but usually the temperature falls to or below 
normal within 24 hours, often yet more abruptly, suffering is 
replaced by relative comfort, profuse sweating and sometimes 
diarrhoea occur and the contrast is often most dramatic. A sim- 



DAY OF 

. ■ : E. - - E 


1 


2 3 4 


5 6 


7 


a 


9 


10 


HOUR 


;■.■ 


MM MM H 


P AP AjP 
'.1 M M M M 


A F 


A P 


m|m 


A P 


107 
















































i !— 










106? 




-p-1 








































-105 


























































£104 




=ffi i 




— 


















































£103 








































































3102" 












































KlOl 


























































^ 100 1 


























































H 

99 






































































































98 












V 




97 


























































96 




























































1 . .I_l_l 


1 1 1 1 . 











Fig. 9. — Clinical Chart of Scarlet 
Fever. (From Wilcox's "Fever 
Nursing.") 



* A severe chill is certainly less generally observed even in pneumonia 
than the student is usually led to believe. 



ANALYSIS OF CERTAIN COMMON SYMPTOMS — COMA. 



57 



ilar fall in temperature in diseases not associated with true crisis 
points usually to a serious complication, in typhoid, for example, to a 
hemorrhage or perforation. In other cases it may be the antemortem 
pseudo-crisis. In pneumonia, a pseudo-crisis of marked degree is often Pseudo- 

r ■"■ crisis, ante- 

followed by renewal of fever, the true crisis occurring ordinarily on the morten- 

day following. In one case of migratory pneumonia observed by the 

author, lobe after lobe of the lungs went through a typical pneumonic 

cycle, the critical fall being promptly followed by chill, renewed fever 

and the usual signs of consolidation in the adjacent lobe.* 



recession. 



■1 103 



m 



SI 



i 



k 



n 



Fig. io.— Clinical Chart of Smallpox showing fall 
of temperature upon the appearance of the eruption 
and its rise upon the incidence of the stage of pustu- 
lation.(From Wilcox's "Fever Nursing.") 

COMA AND ITS CONGENERS.— Coma covers any state of pro- 
longed unconsciousness from which a patient can be aroused only parti- 
ally, temporarily, with difficulty or not at all.f The dividing line between 
different states of unconsciousness and profound sleep is ill defined 
and one merges into the other. The term coma vigil is applied to the Coma vigil 
peculiar complete or semi-unconsciousness of certain cases of typhoid 
fever associated with an open eyed, low muttering delirium. 

*Case of Dr. TT. P. Ritchie. 

fin most instances true coma is associated with a relaxed jaw, ster- 
torous breathing and dry tongue, e.g. morphine poisoning or apoplexy. 



_ 



58 



MEDICAL DIAGNOSIS. 



Causeoften 
obscure. 



Attendant 
conditions. 



Essential 
data. 



Tempera- 
ture and 
humidity. 



Ingesta. 



Data. 



Pupils. 



Stupor and Lethargy. — Both represent sleep or sleepiness, the former 
profound as in alcoholism, the latter a mere drowsiness as in the pre- 
monitory stage of freezing. Assuming that a patient is seen for the first 
time on the street, in the ambulance, hospital or the home, and is comat- 
ose or stuporous, the difficulties in diagnosis are so great as often to 
baffle the diagnostician. Yet many avoidable errors occur through lack 
of proper method and ordinary knowledge and carefulness. The 
conditions under which an attack occurs should be first sought through 
some friend, relation or bystander. The appearance of the patient 
at the time of the attack, his move- 
ments and the direction and force of 
his fall are also to be considered, often- 
times his habits or even his previous 
health may be ascertained. The state 
of the atmosphere may at once suggest 
heat-exhaustion or sunstroke. Inquiry 
must be made as to what the patient 
has taken into the stomach, having in 
mind the possibility of ptomaine or 
drug poisoning, or of sudden deaths 
or severe prostration following the 
overloading of the stomach in victims 
of the diseases of the heart and arter- 
ies. In public services the history is 
often entirely lacking or untrustworthy 

, J . . ° , , / Fig. ii. -Clinical Chart of Acute 

and the physician IS thrown Upon hlS Lobar Pneumonia showing crisis 

xx , J . , upon the seventh day of the disease. 

Own resources. He has to Consider (From Wilcox's "Fever Xurs- 

epilepsy, malingering, strychnia, urce- mg ' 

mia, apoplexy, diabetic coma, poisoning by opium, chloral or other 
narcotics, if delirium is present, belladonna, if convulsions, strychnia, 
and investigates: — 

(a). The Eyes. — Are the pupils equal or unequal, contracted or 
dilated ? Is the conjunctival reflex present, do they react to light, and 
is there resistance to the separation of the lids? Unequally dilated 
pupils (the larger usually on the side of the lesion) suggest cerebral 
hemorrhage or general paralysis of the insane. Contracted pupils 
suggest opium poisoning, or pontine hemorrhage; in uroemia they are 
usually dilated and in all these conditions they fail to respond to light 
and lack the conjunctival reflex. The same is true of cocaine and the 
later stages of chloral poisoning. // convulsions are present with fixed, 



DAT OF 
C15EA5E 


l 


. 


3 


4 


S 


a 


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A f 


A P 


107° 






























































































106 












































































1 105 





































































































| 104 






























































































M 


























J 











tV® 




■ 








— V 


— 






p 
< 102 












































































































■1 

S 101" 
































- 


■ 
















+ 


■ 


















































'A 

100° 










































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— 




1 
























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— j 


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ANALYSIS OF CERTAIN COMMON SYMPTOMS — COMA. 



59 



dilated pupils and absent conjunctival reflex, epilepsy or poisoning 
by strychnia, or some other convulsant is at once suggested. In 
alcholism the pupils may be dilated, but usually respond to light. 
Hysteria and malingering are as a rule readily detected by the prompt 
response to light, and the resistance almost invariably offered to the sepa- 
ration of the lids by the physician. An examination of the background 
may reveal an albuminuric retinitis in uraemia or choked disk in brain 
tumor. 

(b). Color. — In alcoholism the face is usually flushed, in cerebral 
lesions it may be flushed but is usually cyanotic, in uraemia there are 
ordinarily pallor and cyanosis, and this latter may be excessively marked 
in acetanilide poisoning.* 

(c). The Degree of Unconsciousness. The conjunctival reflex 
should be tested in all cases. Sharp pressure over the ovarian region 
may resolve doubt in hysteric females, being often accompanied by a 
complete or partial return to consciousness. The malingerer and 
even the alcoholic individual can seldom resist moving, if such a stim- 
ulus as the sharp pinching of the skin of the inner surface of the arm is 
applied, or the police method of pounding the soles of the feet followed. 
In the other and more serious forms of coma, insensibility is as a 
rule complete. 

(d). The Nature of Convulsive Movement if Present. — In cere- 
bral hemorrhage conjugate deviation of the eyes and head is most com- 
mon. In the comatose terminal stage of strychnia poisoning both head 
and trunk are involved, opisthotonos or emprosthotonos are likely to be 
present and between the attacks the patient may be conscious and 
rational.f In tetanus the convulsive seizures are likely to be limited 
to the neck and jaw, and complete relaxation between seizures does 
not usually occur. In epilepsy the sequence of the seizures, i. e. clonic 
followed by tonic convulsions and the absence of opisthotonos are 
suggestive. The malingerer is foolish to attempt convulsions on account 
of the difficulty of imitation. In hysteria, though often strikingly 
epileptiform or tetanic they are usually irregular and associated with 
the typical hysteric facies, and though the lips may be bitten, the tongue 
is not, whereas in true epilepsy biting of the tongue and incontinence 

* In a puzzling case seen by Dr. Haldol Sneve profound coma and extreme 
cyanosis were explained by the fact that the patient had used as much as 
one or two pounds of a preparation of bromo-seltzer — 40-Sogrs. of acetanilid 
daily for several months. The case recovered. 

t Neither in strychnia poisoning nor tetanus docs complete, persistent 
unconsciousness supervene until the terminal stage and often not at all. 



Epilepsy 
strychnia. 



Alcohol- 
ism. 

Hysteria 
and malin- 
gering. 



Ovarian 
pressure in 
hysteria. 



Alcohol- 
ism. 



Apoplexy. 

Strychnia 
poisoning. 



Tetanus. 



Status 
epilepticus. 



Malin- 
gerers. 

Hysteria. 



6o 



MEDICAL DIAGNOSIS. 



Muscle 
tonus. 



Atrophy. 
Frothy lips. 



High 
tension. 



Fatal 
errors. 



Uraemic 
odor. 



Diabetic 
breath. 



Poisons. 



of urine during the seizures are important signs. In hysterical tetanus 
the eyes are usually closed during a seizure and emotional utterances, 
sobbing, and crying are prominent. The peculiar premonitory ex- 
hilaration and hyperacuteness of the special senses observable in 
strychnia poisoning are absent in hysteria and the onset of spasm is 
atypical. 

(e). Paralysis. — The limbs should always be handled to ascertain 
if paralysis be present in any member, the peculiar lack of all muscle 
tone being usually readily determined and paralysis of the" muscles 
of the eye and face easily noted. If paralysis of the extremities be 
associated with marked atrophy it will of course suggest an old lesion 
which may or may not be related to the patient's present state. Froth 
about the lips, if blood stained, points to epilepsy, but is common to 
many of the convulsive states attended by unconsciousness. Malingerers 
are usually obliged to use soap for this purpose. 

(f). The Pulse.— In cerebral compression the pulse is slow, in 
uraemia its high tension may be suggestive. In malingerers and hyster- 
ical persons it is the pulse oj exertion, rapid, full and bounding and in 
other conditions it is, as a rule, of little value. 

(g). The Temperature. — In all cases the rectal temperature should 
be taken and particularly in the cases apparently alcoholic in their 
nature. One of the commonest mistakes on the part of ambulance and 
police surgeons results from the failure to remember that pneumonia 
and cerebral lesions are extremely common in the drunkard, and may 
occur during the unconscious stage. As before stated the presence of 
fever does not absolutely exclude hysteria and it is present in cerebral 
hemorrhage, the surface temperature being usually a degree or more 
higher on the paralyzed than on the non-paralyzed side. 

(h). The Breath. — An alcoholic odor though suggestive does not 
prove drunkenness. The so-called uraemic breath is reasonably char- 
acteristic, but closely approximated by that encountered in other con- 
ditions, and is a disagreeably aromatic odor that must be learned by 
actual experience. The sweet breath of the diabetic is far more char- 
acteristic and often extremely penetrating* Certain poisons like 
laudanum, carbolic acid, hydrocyanic acid, ether and chloroform 
yield a characteristic odor. 

(i). The Examination of the Urine. — At the earliest moment a 



* The author not lone since detected it in passing upon the open street a 
little babe supposed to be in perfect health but suffering from terminal 
diabetes, as determined by the family physician upon notification. 



ANALYSIS OF CERTAIN COMMON SYMPTOMS — PAIN 



61 



Diagnosis 
often im- 
possible. 



Subjective 
and varia- 
ble. 



specimen of urine should be removed by catheterization and carefully 
examined with reference to contained solids, albumen or sugar. 

Conclusion. — In conclusion it must emphatically be said that but 
few of the differential points given are absolutely distinctive, and there 
is no condition that more greatly taxes the skill and common sense 
of the practitioner. If the breath of a patient smells of laudanum, 
the pupils are contracted, the breathing stertorous, the skin cyanotic, 
and clammy, and particularly if a receptacle that has contained lauda- 
num is found empty, the proof is sufficiently conclusive. Stertorous 
breathing, flushed countenance, slow hard pulse and the evidences 
of paralysis are sufficiently characteristic of a cerebral lesion. On the 
other hand, one often meets with conditions in which he is misled by 
a reversal of ordinary symptoms, contradictory or confused findings and 
a failure on the part of the ailment to observe the man-made laws of 
differential diagnosis. 

PAIN. — Pain as a symptom is purely subjective and may be true or 
false, localized or diffuse, momentary, temporary or persistent and vary 
greatly in intensity. Its differences are indicated by such descrip- 
tive terms as dull, aching, sharp, acute, stabbing, boring, gnawing, 
lancinating, shooting, colicky, radiating, diffuse, etc. It may be deeply 
seated or superficial, and may or may not be associated with tenderness 
due either to actual inflammation or to hyperaesthetic areas. Occasion- 
ally the site of pain is far distant from its source, and indeed certain 
referred pains may be dangerously misleading, for example, the author 
has observed a case* in which an aneurism of the left iliac artery caused 
pain over the appendix, others in which appendiceal pain was referred 
to the left side, yet others in which the pain of gall stone colic appeared 
in the region of the heart, while nothing is commoner than for the pain 
of pleurisy to be referred to the surgical regions of the abdomen along 
the intercostal nerve terminals. 

The Character and Seat of Pain in Relation to Diagnosis. — 
The pain of an acute inflammatory disease is usually associated with 
fever, and often with localized tenderness, the degree of either depending 
upon the nature of the affected structure, the individual susceptibility and 
resistance, and the extent and situation of the inflammatory process. 
In surgical diseases of the extremities, for example, the pain is ordinarily 
associated with distinctly localized tenderness and is of great value as a 
symptom. On the other hand a pneumonia may exist with little or 
no pain or by involvement of the pleura produce excessive pain, hi 

♦Through the courtesy of Dr. Archibald McLaren. 



Referred 
pain. 



Factors in 
severity. 



Variable 



, 



A 



62 



MEDICAL DIAGNOSIS. 



Painless 
inflamma- 
tion. 

Movement 
and pain. 



Relief by 
exudate. 



Radiating. 



Dull. 



Colicky. 

Gnawing 

and boring. 



Gastralgia 
a misno- 
mer. 



Onset. 



McBur- 
ney's point. 



any disease of a viscus inflammation of the substance is almost painless 
until extension to the internal or external layers occurs. Pain is likely 
to be distinctly related either to bodily movement in general, or to 
functional activity of the part affected, for example, friction of in- 
flamed surfaces causes respiratory pain in pleurisy, while in acute 
rheumatism the slightest movement of the affected joint is distressing. 
In all such instances nature seeks to relieve the condition by pour- 
ing out a fibrinous or serous exudate which fact explains the partial 
or complete relief of pain in fully developed cases of pleurisy and 
pericarditis. Radiating pain is most characteristic of neuralgias and 
neuritis, and is recognized by its tendency to follow the known distri- 
bution of nerve trunks and by association with marked tenderness 
over certain areas. Dull pain may take the form of a general aching 
as in the acute infectious diseases, or may attend many of the chronic 
low grade inflammations, particularly such as affect the mucous mem- 
branes and the parenchymatous structures. Acute inflammation or 
irritation of certain mucous membranes may be attended with severe 
pain, as for example, that of renal colic. Gnawing or boring pain is 
frequently encountered in caries of the spine, aneurism of the aorta, 
carcinoma of the stomach and inflammation of bone. It is also met 
with in some cases of old gastric ulcer, in gout, gall stones and renal 
calculus. 

Paroxysmal Pain. — Gall stones, renal colic, colon colic, locomotor 
ataxia, neuralgia and angina pectoris furnish the best examples of 
paroxysmal pain; nearly all radiating pains are distinctly paroxysmal. 

Colic. — The term colic applies chiefly to paroxysmal abdominal 
pain and includes that of biliary or renal calculus, appendicitis, lead 
poisoning, floating kidney (Dietl's crises), mucous colitis, spastic con- 
stipation, strangulated hernia and abdominal aneurism. Many of these 
attacks were formerly covered by the term "gastralgia," but the modern 
surgeon has proven that an actual gastralgia (neuralgia of the stomach) 
is so rare as to be almost negligible. Cases of simple transitory colic 
due to acute indigestion, are common in both children and adults, but the 
utmost caution must be observed in the interpretation of an appar- 
ently simple abdominal pain, particularly if unduly persistent and asso- 
ciated with tenderness on deep pressure. 

Appendicitis. — Many cases begin with general abdominal pain of a 
colicky type and 12 or 24 hours may elapse before it becomes distinctly 
localized at a point of maximum tenderness in the area lying midway 
between the anterior superior spine and the umbilicus (McBurney's 



ANALYSIS OF CERTAIN COMMON SYMPTOMS — PAIN. 



6.3 



Ureteral 
colic. 



Chronic 
cases. 



May simu- 
late appen 
dicitis. 



point). The tenderness may be apparent before the pain becomes 
localized and both are simulated by certain cases of renal colic in which 
a small calculus has become engaged in the lower portion of the ureter. 
Nausea and vomiting at the onset, with fever assist the diagnosis. 
Chronic appendicitis often remains problematic or is only revealed by 
operation, but usually it may be determined by the history, by tem- 
porary exacerbations, or by actual palpation of the affected member. 
The disease is frequently associated with symptoms of chronic indiges- 
tion of an indeterminate type. See page 288. 

Renal Colic— This sudden, intense and agonizing paroxysmal pain 
may result from stone or gravel, either in the kidney pelvis or passing 
downward through the ureter. There may be grunting and straining 
expulsive movements. It has a maximal point over the kidney poste- 
riorly and tends to shoot downward over the course of the ureter into the 
groin along the inner portion of the thigh and into the testicle, which 
is oftentimes retracted during the paroxysms. Unlike appendicitis, 
it is usually afebrile, and dysuria and frequent micturition are associated 
with albumen, blood and gravel or actual calculi in the urine. Nausea 
and vomiting are common and in two instances the author has known 
of narrow escapes from operation for appendicitis apparently because of 
temporary block by calculi at the lower end of the ureter. In renal colic 
tenderness is usually found over the kidney posteriorly, often anteriorly, 
and is best elicited by deep pressure over the 12th rib, or according to 
the author's experience just beneath it, at the end of deep inspiration. 

Dietl's Crises. — May be associated with pain of the same type, with 
more or less tenderness over the region of the movable or floating kidney, 
but more closely simulates gall stone colic than renal colic so far as 
pain distribution is concerned. The incidence and severity of attacks 
bear but slight relation to the degree of kidney mobility. 

Gall Stone Colic. — Is indicated by paroxysmal pain in the epigas- 
trium or right hypochondrium, radiating both upward and downward. 
but chiefly upward, being often felt in the right shoulder joint and under 
the right scapula, and is associated with tenderness on deep pressure 
over the gall bladder at the end of deep inspiration. It is accompanied 
by nausea or vomiting and may or may not be associated with jaundice. 
See page 305. 

Colon Colic. — In association with mucous colitis and with chronic 
spastic constipation, a paroxysmal attack may occur quite as severe as 
that of many renal colics. It is left sided, the maximum point is over 
the region of the kidney, posteriorly, but ordinarily it lacks the typical 



Tender- 
ness. 



Simulates 
grail stone 
colic. 



Often 
severe 



A 



. 



64 



MEDTCAL DIAGNOSIS. 



Relieved 
by pres- 
sure. 

Lead line. 



Tabes, 
aneurism. 



Pressure 
tenderness. 



General 
rule. 



Constipa- 
tion. 

Symptoms 
vary with 
site. 



Tumor. 



Stools. 



Adults 
chiefly. 



Sigmoidal 
cases. 



thigh and groin radiation and is either wholly or in a considerable meas- 
ure relieved by emptying the bowel with hot enemata. 

Lead Colic. — A paroxysmal, diffuse, persistent and recurrent pain 
associated usually with obstinate constipation and relieved rather than 
increased by pressure, should lead one to search for a "blue line"* 
on the gums, or for some source of lead poisoning. The curious parox- 
ysmal pain associated with the crises of locomotor ataxia and the obscure 
and rarely diagnosticated pain of arteriosclerotic abdominal crisis or 
abdominal aneurism must always be borne in mind. 

Colic due to Gastric Ulcer. — Violent paroxysmal pain may be 
encountered in connection with gastric ulcer and the pain is usually 
epigastric, deep seated and often seems to pass through to the back. 
During acute attacks it may be relieved by pressure, more often how- 
ever, as in the chronic form, any pressure is distressing. It is usually 
associated with dyspepsia and anaemia and often a history of hsemate- 
mesis assists the diagnosis. In nearly all forms of abdominal colic the 
onset is sudden, with few or no prodromata and nausea and vomiting 
almost invariably occur. See p. 262. 

Acute Intestinal Obstruction. — Acute obstruction is characterized 
by paroxysmal pain, becoming continuous, and ultimately by fecal 
vomiting. . The obstinate constipation is often preceded by misleading 
evacuations from that portion of the bowel lying below the point of obstruc- 
tion. If the obstruction involve the colon there is less vomiting, marked 
abdominal distension and relatively slight indicanuria. In lower 
ileum or caecal obstruction, the distended coils may form a ladder pattern; 
if in the sigmoid or rectum the descending, transverse and ascending 
colon may be projected by distension as a visible horseshoe curve. 
An actual tumor is rare save in fecal accumulation or intussusception. 
The latter occurs in three-fourths of the cases at the ileo-caecal junction 
and most often in infants, rarely in young adults, with bloody mucoid 
stools and tenesmus. 

Volvulus. — Obstruction due to axial twist seldom occurs in youth, 
most often involves the sigmoid flexure or the region of the caecum and 
is associated with marked meteorism, rigidity and tenderness. Antece- 
dent constipation and flatulence usually exist and in sigmoidal cases 
the obstruction may be so low as to make the condition evident when 
an attempt is made to introduce a large enema. 

Strangulation. — In the adult this is a most frequent source of acute 
obstruction and is most frequently caused by old adhesions, various 

* See also " gums," p. 23. 



ANALYSIS OF CERTAIN COMMON SYMPTOMS — PA IX. 



65 



openings and pockets, slits in the mesentery and omentum, rupture of 
the diaphragm, various hernias, and adhesions of the tip or persist- 
ence of, Meckel's diverticulum. 

Intestinal Paralysis. — In connection with abdominal operation and 
as a result of sepsis and peritonitis, there may be an entire absence of 
intestinal activity leading to what is essentially an acute obstruction 
associated with general distension and recognized by the absence of 
normal sounds upon auscultation. 

Fecal Impaction. — A fecal mass gradually accumulating in an 
atonic bowel may be found either at the caecum or sigmoid flexure and 
may wholly occlude the lumen or contain a central channel through 
which a certain amount of material may pass. A localized peritonitis 
with pain and tenderness may or may not be present and the mass may { 
be felt in the absence of extreme distension. The condition most 
frequently occurs as a result of neglect of the bowels, or in nervous ! 
conditions, in the aged, apathetic, hysterical or insane. 

Of tumors, strictures and occlusion by foreign bodies little need 
be said. Cicatricial contraction results usually from old ulcerations, 
whether syphilitic, tuberculous, dysenteric or simple; less often from 
adhesion. Occlusion by tumor may be due to development of local 
growths, direct pressure, or associated adhesions. 

General Comment. — Early and correct diagnosis is of importance 
in connection with intestinal obstruction, hence the leading features 
should be kept closely in mind. The higher the obstruction the less is 
the meteorism and associated tumors point to an actual growth, intussus- 
ception or fecal impaction* 

Intussusception is most frequent in infancy and childhood, and the 
tumor is usually in the ileo-ccecal or appendiceal region or in the sigmoid 
flexure. In the latter, and in volvulus the lack of fluid capacity of the 
lower bowel may be an important aid. Volvulus is most common in 
the fourth decade. Marked tenesmus and blood x stools arc most frequent 
in intussusception, the passage of ribbon like or greatly narrowed cylin- 
drical stools suggests obstruction, but may occur in cases of fecal 
impaction possessing central calibration or even be due to hemorrhoids 
or rectal spasm. Further, though acute constipation with retention 
of both gas and fecal matter is the cardinal sign of complete obstruction, 
the uuo( eluded lower portion of the bowel may be able to eject its contents. 
Foreign bodies of any kind may cause obstruction and are seldom 
suspcei-cd unless a clear history is obtained. Mosl Frequently the 

* Such impaction may be enormous. 
5 



I'Ost 

operative. 



Ausculta- 
tory sign. 



Site. 

Complete 

or partial. 



Tin 



Ancient 
ulcerations. 



Meteorism 

and tumor. 



Tesl by 
enemata. 



^ 



. 



66 



MEDICAL DIAGNOSIS. 



Drug ob- 
struction. 



Worms. 

Fecal 
vomiting. 



Rectal 
palpation. 



Anaes- 
thesia. 



Normal 

colon 

capacity. 



Jaundice. 



Fever. 



Urine. 



Necessary 
data. 



victims are children or mentally defective patients. The persistent 
administration of large doses of bismuth and magnesia may cause 
obstructive masses, and amongst other rare conditions are bunches of 
intestinal worms, masses of hair, and gallstones which have made their 
way by ulceration from the gall bladder to the bowel.* Fecal vomiting 
may require 24 or 48 hours to develop its characteristic brownish color 
and specific odor. Obstruction may be so low down as to be felt by rectal 
\ palpation and in descending colon and sigmoid obstruction the sphincter 
may be relaxed. Fever is present, but usually slight, thirst is excessive 
and in a few days collapse appears and terminates promptly in death. 

Diagnosis by Inflation and Liquid Injections. — An anaesthetic is 
necessary and should be pushed to full relaxation. Rectal palpation 
should be followed by the introduction of a long tube (Kelly's tube) 
or oftentimes the whole hand may be inserted.f For the injection of 
water which is in every way superior to air, the patient should be 
placed in the knee-chest position, the warm water injected under gentle 
pressure and its passage determined by both percussion and ausculta- 
tion. A normal colon should hold about 8 litres (quarts) and the ileo- 
cecal valve usually blocks any flow into the lesser bowel. In children 
the injection may be varied according to age, though even an infant can 
take from 1 to i\ litres. 

Comment. — The following points should be remembered in connection 
with abdominal pain: — Jaundice when present suggests gall stone 
colic, but its absence is of little consequence as disproving that diagnosis. 
Fever is entirely absent as a rule in colon colic, lead colic, gastric ulcer 
and abdominal aneurism. It is almost invariable in acute appendicitis, 
frequent in gall stone colic, more often absent in renal colic. The 
examination of the urine should never be omitted and may reveal the 
blood and albumin of kidney involvement, the high grade indicanuria 
of ileus, the pale color and increased quantity suggestive of hysteria or 
the actual stone particles of renal calculus. The examination of the 
blood may show leucocytosis due to appendicitis, or the basophilic 
granulation of red cells suggestive of lead poisoning. 

HEADACHE. — The following points should be considered, viz. : — 
(a) location, (b) character, (c) severity, (d) distribution, (e) time 0} occur- 
rence, (f) duration, (g) local tenderness, (h) hereditary predisposition, 
(i) the effect of medication (in syphilis, anaemia, malaria, etc.) and the 
underlying cause. 



* The only way that a large gallstone can escape, 
t This procedure is not free from danger. 



ANALYSIS OF CERTAIN COMMON SYMPTOMS — PAIN. 



6 7 



Anaemic headache affects either the forehead, orbits, vertex, or occi- 
put. It is usually moderate and associated with a sense of pressure, but 
in extreme chlorosis is occasionally so severe as to resemble the headache 
of meningitis. 

Bilious or Dyspeptic Headache. — This toxaemic variety includes 
as etiologic factors or associated conditions, lithaemia, jaundice, the 
dyspepsias and constipation. It is irregular in duration and occurrence, 
frontal and congestive in type and associated with nausea. There is a 
subjective sense of pulsation; a tendency to nausea; it is increased by 
motion and by stooping, and more or less promptly relieved by emesis 
and catharsis. 

Brain Tumor. — This causes persistent headache, usually increased 
at night, associated with nausea and vomiting, and sooner or later 
with optic neuritis. See p. 578. 

Brain Abscess. — This may cause severe and persistent headache 
resembling that of brain tumor but is usually accompanied by a septic 
temperature curve and optic neuritis is usually absent. See p. 586. 

Eye Strain Headaches. — May be either occipital, orbital or frontal, 
are usually associated with use of the eyes for close work, or in certain 
cases for distances, relieved by sleep and frequently associated with , 
conjunctivitis, tenderness of the eyeball or eye muscles and sometimes 
with blurred vision. 

Drug Headaches. — The overuse of drugs may lead to headaches 
which have no distinguishing features. A dull throbbing headache 
associated with ringing in the ear often follows the administration of a 
salicylate or quinine in full doses. 

Bright's Disease. — (See uraemic headaches) p. 350. 

Arterio-sclerosis.— The cause is suggested by rigid temporals or ra- 
dials and by the fact that the headaches are often relieved by the adminis- 
tration of such a drug as nitroglycerine. They are seldom severe though 
often persistent; are frequently associated with impaired memory and 
intellection and transient vertigo and are often forerunners of cerebral 
hemorrhage. 

Malaria. — Both dull, persistent headache and obstinate neuralgia 
may be encountered in connection with malaria. Unless it is distinctly 
periodic, the only characteristic feature is its subsidence under appro- 
priate drug treatment (quinine). 

Migraine. — (Sick headache, hemicrania). Heredity plays a largo 
part in migraine which is regarded by many as an epileptic equivalent. 
Females are most frequently attacked and a considerable proportion of 



Ordinarily 

mild. 



foxaemic. 



Frontal and 
congestive. 



Optic 

neuritis. 



Papillitis 
rare. 



Suggestive 
facts. 



Therapeu- 
tic test. 



J 



68 



MEDICAL DIAGNOSIS. 



Nitrogen 
retention 
cases. 



the cases (30%) commence in childhood (5th to 10th year). Aside 
Various from family taint, conditions such as eye strain, adenoids, carious teeth, 
pelvic disease, gastric disorders, and overexcitement, overstudy and 
dietetic errors are most important. The author has seen a number 
of cases of the most extreme and persistent type associated with a renal 
insufficiency without other signs of the chronic nephritis with which 
headaches of this type are so frequently associated. Periodicity may 
be marked even to the hour of the day, or it may bear a definite and 
invariable time relation to menstruation. 

Symptoms. — The attack appears usually in the early morning, often 
preceded by localized numbness and tingling, hippus, vertigo, visual 
paraesthesias (flashes of light, fortification figures), cramps, spasms, 
or even aphasia associated with mental exhaltation or depression. 
The headache is unilateral, usually right sided and sharp, stabbing or 
boring in character. Nausea and vomiting are common symptoms, 
movement, light and sound increase it, it may become bilateral 
I and extensive and pallor or flushing may be marked. In a periodic case 
recently observed in a young child, the hour of waking, transient aphasia, 
extreme restlessness, nausea and vomiting ushered in a typical hemi- 
crania, which lasted for but two or three hours. Usually the duration 
is one, sometimes two or three days, a night's sleep ordinarily bringing 
relief. In children the possibility of a developing meningitis or brain 
tumor must be remembered. 

Hysteria. — There is no headache characteristic of hysteria and "clavus" 
(pain at the vertex as if a nail were being driven into the skull) has never 
been encountered by the author. 

Neurasthenic Headache. — Usually mild and indeterminate, fre- 
quently occipital, the important characteristic of this form is its morning 
maximum and the tendency to disappear under physical exertion and 
mental preoccupation. 

Nasal Headaches. — This form is characterized by pain originating 
between the eyes and sometimes running backward to the occiput, 
greatly increased by coughing, sneezing or stooping, worse in the morning 
and evening, and relieved by any measures reducing the congestion of, 
or relieving the pressure upon the nasal structures affected. These 
are essentially turbinal or frontal sinus headaches resulting from 
congestion or hypertrophy of the turbinate bones or diseases of 
the sinus. 

NEURALGIA. — The pain of severe neuralgia is acute, radiating, dis- 
tinctly localized and associated with superficial points of tenderness. Its 



Cause usu- 
ally clear. 



ANALYSIS OF CERTAIN COMMON SYMPTOMS — PAIN. 



69 



characteristic feature lies in its definite relation to known nerve trunks, 
their points of exit and their distribution. It may affect any portion 
of the body, though most common in the head, and is usually the 
expression of toxaemia, though frequently initiated by extreme fatigue, 
particularly when associated with exposure to cold and damp. Severe 
attacks are remarkable for persistence and intractibility under treat- 
ment, a tendency to recurrence, often periodic, and to chronicity. The 
tender points in neuralgia represent points of nerve trunk emergence, 
their entrance into muscles, or their terminal filaments. Maximum 
tenderness is usually easily determined and widely diffused sensitiveness 
of the most extreme type is sometimes encountered.* 

Trifacial Neuralgia. — (Tic douloureux). Either the ophthalmic, 
the upper maxillary or the lower branches may be affected, the last being 
the most common, the first the most severe form. In all varieties the pain 
is intense, the point of tenderness marked. If the ophthalmic be chiefly 
affected the pain is especially severe about the region of the eye, which 
is often injected and tender. Lachrymation may be present, and there 
is marked tenderness in the supraorbital region, over the bridge of the 
nose, and occasionally at the occiput and upper cervical spines. Tran- 
sient blindness may occur. If the upper maxillary is chiefly affected 
the maximum pain follows the upper teeth and the maximum ten- 
derness is at the infraorbital canal. With involvement of the lower 
branches the pain radiates to the ear, and along the lower teeth, the 
maximum painful points corresponding to the auriculo-temporal nerve. 
All branches are usually more or less affected, and a severe herpetic 
eruption may occur along the track of the superficial nerves. 

Cervico-brachial Neuralgia.— This variety frequently associated 
with rheumatic affections involves especially the sensory nerves of the 
brachial plexus. It is relatively infrequent, occurs chiefly in women, 
may be due to remote primary causes such as locomotor ataxia, uterine 
disease or carious teeth, and is characterized by the distribution of 
the pain and points of maximum tenderness which may be over the 
ulnar nerve, at the elbow, near the wrists, in the axilla, at the inferior 
angle of the scapula, over the deltoid muscle, or even on either side oi 
the lower cervical spine. Herpes, anaesthesia and vasomotor disturb- 
ances may occur. 

Cervico-occipital Neuralgia.— This affects the sensory branches 
ol the upper cervical nerves, is often caused by cervical caries and usually 



Suggestive 
features. 



Etiology. 



Tender- 
ness. 



Ophthal- 
mic. 



Superior 
maxillary 



Inferior 
maxillary, 



Cervical or 

brachial. 



*The possibility of a renal Inadequacy as ind 
lion of urinary solids should always be borne in 



cated by insufficient excre 
mind 



^ 



7o 



MEDTCAL DIAGNOSIS. 



Etiology 



Pain and 
tenderness 



Duration. 



associated with a point of maximum tenderness midway between the 
mastoid process and the atlas. 

Other Varieties of Neuralgia. — Intercostal Neuralgia. This com- 
mon ailment occurs most frequently in those debilitated by overwork, 
malnutrition, toxaemia or co-existing diseases, and occurs chiefly in 
young adults of the female sex. It is characterized by sudden pain 
in the chest, of the neuralgic type, but slightly affected by respiration, 
yet following the intercostal distribution. The maximum point of 
tenderness corresponds to the exits of both dorsal and anterior branches 
and it chiefly affects the left side. It is ordinarily of brief duration, but 
may last several weeks and is of special importance in connection with 
angina pectoris, pleurisy and the acute pain of intra-abdominal diseases, 
for which it is often mistaken, the pain being sometimes referred to 
superficial nerve endings upon the anterior abdominal wall. 

Herpes Zoster. — Closely resembles intercostal neuralgia, but is 
probably a neuritis. It is usually unilateral, rarely bilateral and is 
associated with an herpetic eruption following the course of the affected 
intercostal nerve. Its pain is atrocious and may precede the eruption 
by many hours. 

Sciatica. — (Sciatic neuritis, sciatic neuralgia). In the presence of 
the ordinary etiological factors, sciatica is usually initiated by exposure 
to cold, wet and excessive fatigue, direct injury, pressure from pelvic 
tumor, chronic constipation or preexisting disease of the vertebra or 
spinal cord. It is characterized by a sudden onset, the intense pain 
following the course of the sciatic nerve, and often extending well up 
into the lumbar region. Intervals of comparative immunity alternate 
Paroxysms, with paroxysms of a most excruciating type, the pain sometimes shooting 
from above downwards and giving the sensation of an actual shock 
as it reaches the heel. Subjective numbness, tingling, and disturbed 
temperature sense may be present. Pressure applied at the middle of 
the thigh, posteriorly, sciatic notch, posterior aspect of the knee and 
calf, the external malleolus or the dorsum of the foot reveals the 
points of tenderness. 

Miscellaneous Neuralgic Pains. — Pain of a neuralgic type may of 
course occur in any region of the body, and be confined to a single 
trunk or even a single terminal, thus it may be limited to the breast 
(mastodynia) , finger (digital neuralgia), the plantar nerves (plantar 
neuralgia), or be associated with the stretching of the plantar ligaments 
in incipient flat foot, in which case the pain is in some instances limited 
to the third and fourth metatarso-phalangeal joints (Morton's foot). 



A neuritis. 



Cause 



Onset. 



Pressure 
points. 



Morton's 
toe. 



ANALYSIS OF CERTAIN COMMON SYMPTOMS — PAIN. 



V 



Lumbo-abdominal neuralgia is characterized by pain in the back, 
buttocks and loins, radiating to the genital and hypogastric regions, 
and areas of superficial tenderness. It is commonly associated with 
general debility, chronic constipation, disease of the pelvic organs 
and exposure to wet and cold under conditions of fatigue. In femoral 
neuralgia the pain is limited to the front of the knee and the outer front 
of the thigh. In diseases of the hip joint the reflex knee pain (inner 
aspect) is extremely common. 

NEURITIS. — The distribution of neuritic pains and their general 
characteristics are much the same as neuralgia, though much more 
severe and persistent. The disease may be acute or chronic, circum- 
scribed and limited or widespread and multiple. Distinctly inflam- 
matory in type it tends to produce primarily and essentially a degener- 
ation of the affected peripheral nerves. Aside from the more persistent 
and constant character of the pain, the exquisite tenderness on pressure 
is characteristic. Furthermore, there is a special tendency to marked 
cutaneous hyperesthesia followed by anaesthesia and such marked 
changes as redness or pallor, edema or joint swelling and herpetic 
eruptions. In the extremities the skin often becomes characteristically 
glossy, and disturbances of nutrition are indicated by muscle atrophy, 
the reaction of degeneration, loss of dependant reflexes, changes in the 
nails, loss of hair, desquamation of the epidermis, etc. True swelling 
of the nerve trunk and erythema indicating its course may be present 
and if the motor fibres are affected, changes appear, varying from a 
sense of fatigue and slight loss of power to actual paralysis. 

MUSCULAR RHEUMATISM.— This common and painful ailment 
most often affects the lumbar muscles (lumbago), muscles of the chest 
and the cervical muscles (rheumatic torticollis). In all, the chief charac- 
teristic is pain on movement, which produces more or less character- 
istic attitudes, almost complete loss of function and voluntary rigidity. 
One of the most important points of distinction as between this painful 
affection of the muscles and neuralgia, neuritis, pleurisy, and such 
other affections as it may simulate, lies in the fact that tenderness of 
the muscles themselves when grasped is a prominent feature, further- 
more, the pain is distinctly related to muscular movement, and is absent 
or greatly ameliorated when the patient is at rest. Th's disease is 
undoubtedly closely allied to that form of rheumatism which chiefly 
affects the tendons and in many cases originates in those structures. 

General Comment.— Tn general it may be said of pain that in the 
vast majority of painful ailments the seat of pain represents more or less 



Femoral 
type. 



Severe and 

persistent 

pain. 



Tenderness 
extreme. 



Cutaneous 
symptom. 



Trophic 
changes. 



Paresis or 
paralysis. 

Lumbago, 
pleuro- 
dynia. 

Torticollis. 



Muscle 
tenderness, 



Rest re- 

Ue\ os pain. 



7- 5 



MEDICAL DIAGNOSIS. 



Signifi- 
cance of 
seat. 



Shoulder. 



Knee, 
groin, 
thigh. 



Head. 



Lower 
spine. 



Scapula, 
abdomen. 



Epigas- 
trim and 
waist line. 



Interscap- 
ular and 
mid-dorsal. 



Lower 
lumbar. 



Heel. 



exactly the location of the affected part, and any attempt to list the 
enormous variety is futile and useless. The more important referred 
pains are described under the diseases of the different organs. It should 
be remembered however that shoulder pain may be due to local disease 
of the joint, neuralgic disease of the diaphragm or flexures of the colon, 
angina pectoris and, on the right side especially, to inflammatory dis- 
eases of the liver, duodenal abscess, and movable kidney or gall stones. 
Pain at the inside of the knee suggests hip joint disease; down the front 
oj the thigh, ovarian and testicular disease or sometimes a developing 
femoral or inguinal hernia. Pain radiating to the fold of the groin or to 
the testicle is common in renal colic. Headaches have already been dis- 
cussed and the author is not convinced that they conform to any arbitrary 
classification according to location, though such has been attempted. 
Sacral and mid-lumbar pain is frequently of uterine origin and movable 
kidney often produces a painful area over the sacro-iliac joint. Neu- 
ralgic coccygeal pain indicates coccygodynia but equally sharp pain may 
accompany rectal fissure. Pain under the scapula most commonly 
indicates hepatic lesions if on the right side, splenic if on the left. Lower 
abdominal -quadrant pain suggests colitis, sigmoid irritation, appendi- 
citis, ovaritis or varicocele. 

Pubic pain is chiefly attributable to the pelvic organs and cys- 
titis. Pleurisy and its referred pains are discussed elsewhere. Epi- 
gastric pain covers duodenal ulcer, appendicitis, gastric disease, 
(neuroses, displacement), pancreatic and vertebral diseases, pleurisy, 
pneumonia, etc. The girdle sensation conforms to the waist line and 
represents constriction rather than pain. It points to injuries or tumors 
of the spinal cord and its meninges, chronic myelitis and locomotor 
ataxia. In the back interscapular pain is often troublesome and nearly 
always indicates mere indigestion or flatulent distension through aneu- 
rism, gastric ulcer and caries must not be forgotten. Median pain at 
the shoulder level may also occur in aneurism, pericarditis and diaphrag- 
matic irritation. Ulcer of the stomach may produce median pain lower 
down with tenderness to the left of the spine over the ioth and nth inter- 
spaces. A loaded colon, spastic constipation or mucous colitis may pro- 
duce distress in the same region. Aside from these factors backache, 
usually low down, may indicate neurasthenia, pelvic disease, excessive 
fatigue, spinal caries, renal disease (loin weariness is especially common), 
excessive venery and various other conditions. Pain in the heel may 
be due to sciatica, gout, ovarian and testicular lesions, intra-abdominal 
growth or prostatic disease. General aching is a common symptom 



ANALYSIS OF CERTAIN COMMON SYMPTOMS — TENDERNESS. 



73 



Frequently 
syphilitic. 



of nervous and muscular debility or fatigue, usually precedes the onset 
of acute infectious diseases, and is common in chronic rheumatism, General. 
trichiniasis, scurvy, locomotor ataxia, gastro-intestinal or hepatic dis- 
eases and anaemia. 

TENDERNESS. — In general, tenderness is associated with pain and 
conforms in position to the organ affected. Only a few important varia- 
tions will be noted. 

The Head. — A tender scalp suggests syphilis, hysteria, rheumatism, 
neuralgia and migraine. Tenderness of the malar bone — neuralgia or 
antrum disease; of the mastoid process a mastoiditis. Tenderness at 
the back of the neck, caries and neurasthenia; linear or interrupted 
spinal tenderness, neurasthenia, rheumatism, caries, periostitis, actual 
spinal disease and hysteria. Lumbar tenderness is common in lum- 
bago and inflammatory disease of related intra-abdominal struc- 
tures; dorsal tenderness in advanced thoracic aneurism or posterior, 
mediastinal tumors of any kind. A tender sternum or ribs suggests 
ostitis or periostitis; abdominal tenderness is related to all acute and 
many chronic diseases of the contained viscera and if superficial suggests 
neuralgia, referred pleuritic pain or hysteria. Hypogastric tenderness 
is usually directly related to acute or chronic inflammation of the under- 
lying structures. The tenderness of sciatica like its pain occurs chiefly at 
the sciatic notch, the middle of the thigh and knee, the ankle and heel. 
Joint tenderness is often puzzling and suggests rheumatism, arthritis 
deformans, synovitis, gout, gonorrhoea, tuberculosis, sepsis, hysteria or 
simple sprain according to the conditions developed by the case history. 

PERVERSIONS OF SENSATION.— Paresthesias.— The dis- 
turbances of sensation so denominated may be wholly unrelated to 
organic disease of the brain or cord Amongst the more important are 
(i). Sensations of heat and cold. — These suggest neurasthenia, 
malnutrition and anaemia, as well as hysteria, lateral sclerosis, syring- 
omyelia and locomotor ataxia. In profound toxaemias such as alcohol- 
ism or in actual disease of the cord they are usually combined with 
other paraesthesias. The distribution may be general or local, indef- 
inite, or exactly like actual contact with a cold object. 

(2). Formication and Itching.— Itching may be pronounced in 
hysteria, neurasthenia, chronic alcoholism or gout, lead poisoning and 
various diseases of the cord. It is almost invariable in jaundice ami 
one of the signs indicating the taking of morphine (nose rubbing). 
Both itching and formication may antedate or follow an apoplexy and 
the latter is a common symptom both as a result of actual irritation. 



Morphin- 
ism. 



J 



74 



MEDICAL DIAGNOSIS. 



Cocain- 
ism. 



Precordial. 

Epigastric. 

Cephalic. 
Pelvic. 

Serious. 
Trivial. 



Usually 
functional. 



Usually 
neuras- 
thenic. 



Hysteria. 



diseases of the brain and cord, diabetes, cocainism and pelvic disturb- 
ances. (3) . Numbness and Tingling. — Often associated with decided 
burning sensation these symptoms are especially common in connection 
with neuritis or pressure irritation of nerves and such drugs as aconite, 
in addition to the causes of formication and itching before mentioned. 
(4). Oppression. — Precordial oppression is common in mediastinal 
tumors and cardiac disease, as well as in certain pulmonary lesions. 
In haemoptysis it may localize the process and either precede or accom- 
pany the hemorrhage. Epigastric oppression may also be present in dis- 
ease, but is more common in the functional disorders or in haematemesis. 
Head constriction or pressure is almost invariable in hysteria or neuras- 
thenia and pelvic oppression or "bearing down", is usually due to 
actual pelvic disease or in the male to diseases of the bladder. (5) 
Faintness and Sinking Sensations. — In angina pectoris these form 
with severe pain an agonizing and terrifying condition. Lesser degrees 
are common in gastro-intestinal ailments (chiefly functional), in all 
of the cardiac diseases, in neurasthenia, hysteria and especially in 
hypochondriasis. Syncope or faintness may be purely a nervous 
manifestation, sometimes related to peculiar sights, sounds or violent 
emotion, or it may suggest actual disease of the heart or blood vessels, 
follow the aspiration of ascites or pleural exudates, slight hemorrhage 
or surgical operation, or result from pain, exhaustion, heat or the over 
administration of certain drugs. (6). Heat and Morbid Flushing. 
— Fatigue, nervous exhaustion, hysteria, pelvic disease and the meno- 
pause are the most frequent causes of flushing (hot flashes) and in 
certain individuals causeless blushing is a troublesome phenomenon. 
The sensation of epigastric heat known as pyrosis is frequently associated 
with a sense of excessive fullness as distinct from the pressure sensation 
previously described. It is most common in the functional disturb- 
ances of the stomach and in flatulence. (7). Subjective Weakness. — 
In hysteria and neurasthenia or in mere temporary brain fag the patient 
may experience a sense of positive physical fatigue, or, in the former, 
pseudo-paralytic symptoms either transient or persistent. In neuras- 
thenia the "exhaustion' may entirely disappear under active and 
strenuous exertion or be forgotten in the interest excited by a good 
play or a good book. It is frequently due also to the overuse of tea, 
coffee and tobacco, or insufficient sleep. (8). Globus Hystericus. — 
Is a sensation of obstruction, constriction, pressure, or tickling referred 
to the throat, is characteristic of hysteria and may be associated with 
troublesome spasm. 



ANALYSIS OF SYMPTOMS — INSOMNIA, VERTIGO. 



75 



INSOMNIA. - This troublesome symptom may take the form of 
inability to sleep, disturbed sleep, starting during sleep, early waking or 
prolonged wakeful periods. Its causes are too varied to permit full dis- 
cussion here, varying as they do from mere temporary nervous excite- 
ment to actual organic disease of the brain. Inquiry should always be 
directed to the condition of the stomach and bowels, the amount of 
mental work done, amount of tea, coffee, tobacco and alcohol con- 
sumed, amount of exercise taken, the presence of any unusual sources 
of worry or mental strain, excessive study at night and, the age of the 
patient. Old people are as a rule, early wakers and relatively light 
sleepers, the conditions of childhood being reversed. Frequently a 
slight modification in the diet, hours of meals, relation of exercise to the 
meals, the cutting off of excesses of any kind or the mere admission of 
fresh air at night to the sleeping room will put an end to the attacks. 
If neurasthenia be the cause nothing short of a prolonged rest or rec- 
reation cure is of any use. Occasionally climatic change alone will 
produce sleep and permanently correct the disturbance. In acute dis- 
eases the amount of sleep is important and should be carefully noted. 

VERTIGO. — This is in most instances a trivial and transitory symp- 
tom depending upon disturbances of digestion or neurasthenia, but 
nevertheless should always receive careful attention. In the young the 
causes are usually trivial and removable. In the middle aged and old 
it is much more significant. The lines of investigation indicated are 
as follows: — The Existence of Neurasthenia. This condition covers by 
far the greater number of cases, associated as it is with digestive trouble, 
eye strain, hysteria, lithaemia, use of narcotics or stimulants, etc. 
Meniere's Disease. A condition supposed to be due to disease of 
the labyrinth or semi-circular canals and characterized by the association 
of vertigo with tinnitus aurium and a tendency to fall to the right or 
left. See p. 565. Arteriosclerosis and. Cardiac Disease. This vertigo 
covers the greater number of cases observed in elderly people and 
is important as related to ;hreatened apoplexy, to aneurism, aortic 
regurgitation, other cardiac lesions or cerebral disturbances due to 
other causes. Sunstroke or Heatstroke. Sometimes leave behind a 
marked vertiginous tendency. Eye Strain. Errors of refraction and 
ocular insufficiencies should be carefully investigated. Epilepsy. 
Vertigo may be either an aural manifestation of major epilepsy, or 
represent an attack of petit nial. The Habits. -In regard to the use 
6f tea, coffee, tobacco, alcoholics and the question oi sexual excess these 
should be carefully investigated. Brain tumors, cerebral syphilis, loco- 



Necessary 
data. 



Usually 
trivial. 



Age. 



Peculiar 
syndrome. 



Common 
cause, in 
the old. 



Excesses 



7'. 



MEDICAL DIAGNOSIS. 



motor ataxia and Bright' s disease are some of the many conditions of 
which vertigo is a symptom. 

Varieties of Vertigo. — Vertigo is usually sudden in onset and inter- 
mittent or periodic in type. It may take the form of a subjective 
sensation of whirling or falling which persists with the eyes closed, 
or it may occur only when looking at moving objects, riding, driving, 
swaying, or swinging. It usually disappears or is greatly relieved 
: when the patient is lying down, but in some instances, and notably in 
i its arteriosclerotic form it is increased by lying down. Very often a 
sudden change from the recumbent to the erect posture produces it, 
and it may be limited to the early morning hours. 

Points to be Remembered. — Persistent vertigo not distinctly associ- 
ated with digestive disturbances or neurasthenia demands a thorough investi- 
gation oj the heart and blood vessels, the urine, the reflexes, a history of 
syphilis, of possible epilepsy and the symptoms of brain tumor including an 
examination of the fundus oculi* 

DYSPNCEA. — The term "dyspnoea" should be limited to those cases of 
difficult or greatly accelerated respiration in which there is insufficient 
oxidation of the blood due either to actual obstruction to the free ingress 
or egress of air, a diminished pulmonary area, or impairment of the 
chemical exchanges of the blood. The term " accelerated breathing^ 
should cover other varieties. Dyspnoea may be purely subjective, but 
is usually both subjective and objective, and is generally associated 
J with varying degrees of cyanosis. Any condition preventing the free 
entrance of air into the lungs will cause it, hence it accompanies severe 
quinsy and narrowing or stenosis of the glottis, trachea or bronchi, 
whether the cause be direct obstruction as from tumor or foreign bodies; 
inflammation, as in the case of laryngeal diphtheria and broncho- or lobar 
pneumonia; or spasm, as in croup or asthma. Other cases are referable 
to circulator}- disturbances, especially those of the congenital type, 
or incompensated mitral and tricuspid lesions, in which cases the condi- 
tion is largely one of pulmonary stasis, the aeration areas being normal 
but the blood current obstructed and its chemical exchanges diminished. 
In other instances both factors are concerned, as for example in emphy- 



Subjective 

vs. 
Objective. 



Effect of 
posture. 



Scope of 
inquiry. 



Definition. 



Causes. 



Subjective 

vs. 
Objective. 

Obstruc- 
tive. 



Circula- 
tory. 



* In a recent case a persistent vertigo was only explainable through the 
history of a severe accident, probably associated with unrecognized fracture 
at the base of the skull, an incident almost forgotten by the patient and not 
developed by the first examination. In another Meniere's syndrome was 
present in great part but associated with marked middle ear disturbance, 
valvular leakage and profound neurasthenia, and largely disappeared after 
a few weeks. 



ANALYSIS OF CERTAIN COMMON SYMPTOMS— DYSPNOEA. 



77 



sema where there is both pulmonary stasis and insufficient air exchange, 
and to a less degree the same conditions prevail in pulmonary fibrosis, 
the pressure of pleural and pericardial effusion and advanced pulmonary 
tuberculosis. In the last instance the amount of dyspnoea is often 
strikingly disproportionate to the area of lung involved though usually 
marked upon exertion. In severe anaemias the impaired haemoglobin 
content alone or a combination of circulatory and haemic insufficiency is 
accountable. 

Stertorous Respiration. — In profound coma, extensive post nasal 
adenoids, or greatly enlarged tonsils as well as in ordinary deep sleep 
in certain individuals there is a snoring respiration which is not however 
a true dyspnoea in most instances. 

Stridor. — Stridulous breathing is invariably of laryngeal origin and 
usually due to spasm, paralysis, edema, foreign bodies, membrane, 
tumor or severe inflammation of the glottis. In certain cases it repre- 
sents pressure and resulting spasm or paralysis of the laryngeal muscu- 
lature as in aneurism, enlarged bronchial glands, massive pericardial 
effusions, etc. It is typified by the "crowing" of a croupy child, and 
invariably represents true dyspnoea of the obstructive or stenotic type. 
Its diagnostic features are stridor and a pronounced vertical move- 
ment of the larynx, the descent in inspiration being oftentimes so great 
as to embarrass the surgeon in tracheotomy. The breathing is slow in 
obstructive dyspnoea so long as respiratory power remains good. 

Air Hunger. — This peculiar form of dyspnoea is best illustrated in 
diabetic coma and best olescribed by the name given. 

Dyspnoea on Exertion. — This accompanies severe chronic bron- 
chitis, emphysema, early tuberculosis, pleural effusion of the latent 
type, anaemias, exhausting diseases or debility, obesity and imperfectly 
compensated cardiac lesions. 

Persistent Dyspnoea. This indicates severer grades of the condi- 
tions mentioned in the preceding paragraph, stenosis of the air pas- 
sages or certain profound toxaemias. It is particularly marked in 
obstructive lesions, terminal cardiac incompensation and advanced 
emphysema. 

Paroxysmal Dyspnoea. --The commonest forms are croup and true 
asthma, the one being an inspiratory dyspnoea, the other predominat- 
ingly expiratory. Spasm ot the glottis may be associated with hysteria 
or organic nervous disease, bul true bronchial asthma may be perfectly 
simulated by dyspneeic paroxysms sometimes observed in uraania and 
by a paroxysmal dyspncea associated with cardiac lesions for which 



Pressure. 

Phthisis. 



Anaemia. 



Usually 

glottic 

stenosis. 



Croup. 



Important 
sign. 



Rhythm. 



I >iabetes. 



Signifi- 
cance. 



Group, 
asthma. 






78 



MEDICAL DIAGNOSIS. 



Cardiac. 



Glottic 
tumors. 



Asthma. 



Broncho- 
pneumonia. 



the term cardiac asthma should be reserved. The ordinary form 
essociated with cardiac disease being non-paroxysmal and usually 
axtreme only under exertion, or the pressure of secondary transudates. 
Pedunculated tumors below the glottis may cause violent and even 
fatal paroxysmal dyspnoea. 

Associated Changes in the Chest Outline. — Certain permanent 
changes such as the forced inspiration type of emphysema, the uni- 
lateral enlargement of chronic pleural effusion or tumor and the unilat- 
eral retraction of fibroid phthisis and pleural adhesion need no further 
description here. In asthma, the lower diameters of the thorax are 
especially increased during the paroxysm because of the expiratory 
type of the spasmodic dyspnoea. In broncho-pneumonia and other 
forms of obstructive dyspnoea a marked inspiratory narrowing and reces- 
sion of the interspaces occurs because of the inspiratory negative pres- 
sure and the direct drag of the diaphragm. This need not be confused 
with the slighter contraction sometimes observed in chronic emphysema, 
enteroptosis and even in normal individuals. 

Orthopnoea. — This term refers especially to the sitting attitude 
necessitated by extreme dyspnoea in the recumbent posture, and is 
most commonly noted in cardiac incompensation, or conditions pro- 
ducing pressure within the mediastinum. In some instances the patient 
must not only sit up, but is more comfortable leaning forward.* 

Subjective Dyspnoea. — The mere sensation of dyspnoea is practi- 
cally limited to hysteria or neurasthenia, and even though orthopnea 
be present there is no associated cyanosis. 

VARIATIONS IN RESPIRATORY RHYTHM.— Mere irregular- 
ity is common in children whether awake or asleep. It also appears as an 
ominous sign in massive cerebral apoplexies, brain tumor, meningitis, 
shock and collapse, and not infrequently as a symptom of chorea. 

Jerky Respiration. — This may be inspiratory as in hydrophobia, 
asthma or hysteria or expiratory and often grunting in intercostal neu- 
ralgia, acute pleurisy, rib fractures, stab wounds, renal and gall stone 
colic, or, in the presence of any paroxysmal pain especially of the abdo- 
men. Wavy inspiration characterized by an undulatory movement of 
the chest may be noted in severe typhoid, pneumonia and other condi- 
tions associated with great prostration. 

Biot's Respiration. — This term applies to respiration interrupted 



Usually 
cardiac or 
mediasti- 
nal. 



A neurosis. 



jrunting. 



Wavy. 



* It has been stated that this latter position is pathognomonic of acute 
aortitis, but in the author's personal experience it is a common symptom 
in mediastinal new growths. 



ANALYSIS OF SYMPTOMS — RESPIRATORY RHYTHM. 



79 



regularly or irregularly by apnoeic intervals of varying length. In 
a moderate form it may be encountered in pneumonia, but is ordinarily 
a precursor of death in various affections. 

Cheyne-Stokes Breathing. — This covers also irregular breathing 
interrupted by apnceic intervals but characterized by the fact that, 
following a pause, the respiration recommences as shallow slow breathing, 
increasing in depth and frequency until a maximum is reached, when 
it subsides in the inverse order. It ordinarily accompanies the coma 
of organic disease of the brain, apoplexy, uraemia, myocardial degener- 
ation and meningitis. It may also be observed in diabetes and various 
acute infections, such as cerebro-spinal fever, septicaemia, typhoid, 
pneumonia and the exanthemata. In normal children it may occur 
during sleep, in the adult suffering from chronic disease of some of the 
types mentioned it may be present both waking and sleeping for long 
periods, and in a case reported by Osier was so severe and troublesome 
as to interfere with eating. It is usually a precursor of death never- 
theless. Traube's theory of lowered irritability of the respiratory 
centre if combined with the fatigue hypothesis of Rosenbach would 
adequately cover the phenomenon. 

Increased Frequency. — Mere fever increases frequency as do most 
dyspnoeas not stenotic in type. 

Hiccough. — This sudden spasmodic contraction of the diaphragm 
often temporary and negligible may become one of the most serious 
complications of acute or chronic disease. The attacks, ordinarily 
short, may be prolonged for days or weeks and rapidly exhaust the patient. 
It may be due (a) to organic or functional disease of the nervous system, 
(b) of the abdominal organs, (c) constitutional diseases, (d) miscellaneous 
causes such as severe acute infections, the typhoid state, alcoholism, 
pneumonia, pulmonary gangrene, chronic heart disease, pregnancy, 
etc. It would be useless to give in detail the various conditions with 
which it is associated as it may occur in any exhausting disease, acute 
or chronic. Occurring with inflammation of the diaphragm whether 
from the pulmonary or peritoneal side it constitutes an agonizing 
complication. 

SHOCK AND COLLAPSE.— The symptoms are —lowered tempera- 
ture, cold wet surface, weak thready pulse, great prostration, pallor. Hip- 
pocratic countenance or an expression of great anxiety, combined with 
extraordinary mental clearness. Previously existing pain and distress 
are often greatly relieved and occasionally misinterpreted by both 
patient and physician. It is commonly associated in iue v lieine with 



Peculiar 
rhythm. 



Serious 
sign. 



Ambula- 
tory cases. 



Often 
serious. 



Etiology. 



Misleading 
signs. 



8o 



MEDICAL DIAGNOSIS. 



Usual 
causes. 



Shock and 
collapse. 



those intra-abdominal diseases which have a surgical side, for example, 
perforating appendiceal, gastric, or duodenal ulcer, hepatic abscess 
and acute hemorrhagic or suppurative pancreatitis. Amongst other 
causes are strangulated hernia, severe accidents, particularly those 
attended by crushing violence, and, in its lesser degrees, even in the 
severe acute infections, renal and hepatic colic, and in conditions like 
angina pectoris associated with extreme pain. Its symptoms should 
be clearly borne in mind and its major form strongly suggests a dan- 
gerous and probably terminal complication of some existing ailment. 

Concealed Hemorrhage. — An extensive open hemorrhage almost 
invariably greatly alarms and excites its victim; internal and concealed 
hemorrhage presents symptoms of shock and collapse together with a 
certain curious restlessness and oftentimes yawning, nausea and air 
hunger. In any case of shock or collapse the stools should be carefully 
examined for blood and in married women the possibility of ectopic 
gestation cannot be ignored. The clear mind of the earlier stage may 
yield to delirium and occasionally there are convulsions. 

Sources of Concealed Hemorrhage. — Amongst the most common are 
hemothorax, aneurismal rupture, duodenal ulcer, typhoid, gastric 
ulcer, ectopic gestation or pelvic hematocele from any cause, traumat- 
ism, the hemorrhagic diathesis and very rarely in pulmonary tuber- 
culosis a large hemorrhage into an old cavity may for a time be con- 
cealed.* 

DISEASES OF THE THORACIC VISCERA. 



THE TOPOGRAPHICAL ANATOMY OF THE CHEST.— The 
Regional Divisions. — The angulus Ludovici or angle of Louis, a ridge 
marking the junction of the manubrium with the gladiolus of the 
sternum, indicates the lower border of the aortic arch, the bifurcation of 
the trachea, the junction of the borders of the right and left lung, and 
The nipple. . the second rib. The nipple indicates, ordinarily, the fourth inter- 
space but is subject to marked variation in position, particularly in the 
female. The lower border of the pectoralis major should correspond 
to the upper border of the sixth rib, and, posteriorly, the upper portion 
of the scapula corresponds to the second rib; its inferior angle to the sev- 
enth or its interspace; the root of its spine to the third rib and the 
right inter-lobar fissure, a region most important in connection with 
invasion by the tubercle bacillus. The modern regional divisions 

* For Haemoptysis see p. 156. Haemalemesis p. 250. Epistaxis p. 118. 



The sterna 
angle. 



The great 
pectoral. 



The 
scapula. 



Interloha 
fissure. 



DISEASES OF THE THORACIC VTSCERA. 



8. 



and orientation lines necessary to verbal or written description, are 
clearly shown by the plates. 

The Thoracic Viscera. — The heart with its great vessels, the lungs 
and their primary bronchi, are contained viscera, the liver, spleen and 




Fig. 12. — Regional Divisions of 
the Chest, (Posterior surface- 
verticals), a, a. Scapular lines. 




Y\a. 14. — Percussion 
Areas, Normal Chest. 
(Anterior Surface.) 
Lungs — red. Liver — 
horizontal black lines. 
Relative cardiac dul- 
riess— v erti c a 1 black 
lines. Absolute cardiac 
dulness— cros s-h a t c h- 
im*. Stomach tympany 

oblique red lines. 




c b a a b c 

Fig. 13. — Regional Divisions of 
the Chest, (Anterior Surface- 
verticals. The various ana- 
tomic divisions are plainly 
indicated, a, a. Sternal lines. 
b, b. Parasternal lines, r, c. 
Mammillary or nipple lines. 




Fig. 15.- Percussion Areas. 
(Normal Chest, Posterior Sur- 
face), a. a. Lungs. b,b. Pleu- 
ral space. . . Spleen. c. 1 ,i\ er. 
(/,</. Kidneys. Area b, b yields 
percussion dulness from 
spleen, kidneys, and liver, un- 
less lungs are distended. 



" Con- 
tained' 

vs. 
" Shel- 
tered." 






kidneys, and even a part of the stomach are sheltered viscera, though 

actually sub -diaphragmatic and abdominal. 

The Lungs. -The lungs occupy nearly all the upper chest, their J un« 

. . ' . . . boundane 

apices extending to the level ol" the seventh cervical spine behind and 

6 



^ 



82 



MEDICAL DIAGNOSIS. 



Superficial 

cardiac 

area. 



Liver 
dulness. 



Diagnostic 
uses. 



Pleural 
sinuses. 

Shifting 
dulness. 



Delinea- 
tion. 



Relation to 
surface. 




an inch to an inch and a half above the clavicle in front. The right is 
slightly higher than the left, and their resonance may be elicited over 
the whole of the supraclavicular and suprascapular regions. Their 
anterior borders meet at the sternal angle and, in contact, pass vertically 
downward to the level of the fourth cartilage; thence the left lung passes 
outward, forming the left border of the superficial cardiac area and the 
right continues downward to the sixth cartilage and in the midclavicular 
line both lower borders are represented by that rib. In mid-axilla 
they cut the eighth; in the scapular line, the ninth, and near the spine 
reach the level of the tenth spinous process. From the midclavicular 
line outward the lower border is practically horizontal. Below is an 
important area including the liver, spleen, stomach and 
kidneys. The liver lying beneath and adapting itself 
to the dome-like surface of the diaphragm, rises into 
the thorax to a much greater degree than is shown 
readily by percussion, but absolute liver dulness be- 
gins at the lower border of the lung and extends 
downward to the costal margin.* 

Traube's Semi-lunar Space. — This is included 
between the lower border of the left lung, the spleen, 
the inferior costal margin, and the left lobe of the 
liver, and is normally hyperresonant because of the 
underlying stomach. The pleura extend much lower 
than the lung margin, being two inches inferior in 
the mammary line; reaching a maximum of four 
inches in mid-axilla, and one and one-half inches in 
the scapular line. It will thus be readily seen that 
any small effusion of fluid into the left plural sac will, if free, produce an 
area of movable or shifting dulness in Traube's space, and that any 
increase in the size of the left lobe of the liver or of the spleen may re- 
duce its lateral dimensions. 

The Lobes of the Lung. — A line drawn from the second dorsal spine 
under the armpit to the middle of the sixth costal cartilage, divides the 
lung into its upper and lower lobes. On the right side a second line 
drawn from the middle of the first line to the fourth chondro-sternal 
joint marks the upper boundary of the middle lobe. The front of the 
chest, therefore, largely represents the upper, the back Hie lower lobe, the 
apex being accessible both anteriorly and posteriorly, and the middle lobe 
on the right occupying a portion of the axilla and the anterior surface. 

* For a description of the hepatic and splenic areas see p. 225. 



Fig. 16. 
Traube's space. 
Bounded by the 
lung, spleen and 
liver and the cos- 
tal margin. Shows 
region of pleural 
sinus in which 
movable dulness 
may appear in 
left-sided pleural 
effusion. 



DISEASES OF THE THORACIC VISCERA. 



83 



The Heart. — The heart lies in the mediastinum between the lungs and Hound 
presents :•*— (a). A base, at the level of the upper border of the third costal 
cartilages, (b). A right border, curving from the right base downward 
to the sixth chondro-sternal articulation and attaining a distance of one 
or one and one-half inches from the right sternal border under the 
fourth cartilage, (c). A left border, which curves outward almost to 
the midclavicular line, and then inward to a point one inch within that 
line in the fifth interspace, (d). A lower border connecting the lower 
extremities of the lines representing the right and left borders. 

The Aorta. — From the base, the aorta sweeps upward and to the 
right, its right border projecting slightly beyond the sternal margin, 
it passing backward and toward the left in such a manner as to leave 
the manubrium resonant under normal conditions. 



Bound- 
aries. 





Fig. 17. — Lung Bound- 
aries. (Anterior Surface.) 
(Modified Pansch-Fow- 
ler.) 



Fig. 18. — Relation of Heart 
and Great Vessels to Chest- 
wall. The lungs are pulled 
aside. — (After Sibson.) 



Mobility of the Heart.— Suspended within the pericardial sac by the 
great vessels at its base, the heart is movable and markedly displaceable 
under certain pathologic conditions. Anteriorly it presents its right 
chambers, chiefly the right ventricle, the left being normally represented 
by a mere strip of heart muscle along the left border. The notched border 
of the left lung leaves a portion of the right ventricle uncovered and in 
such close proximity to the chest as to yield decided percussion dulness 
over a somewhat triangular space having its base at the left sternal margi,' 
from the fourth to the sixth chondro-sternal articulation and its apex at 
or just within the apex-beat the triangle being completed by lines connecting 
these points. (See fig. 14.) 

Area of Relative Dulness.— It is so difficult to accurately outline 



Manu- 
brium per- 
cussion 
note. 



Anterior 
aspect. 



superfi- 
cial " car- 
diac area. 



^ 



84 



MEDICAL DIAGNOSIS. 



Practical 
outline. 



Anatomica 
position un 
important. 



Methods 
employed. 



Know the 
normal. 



Avoid 
repetition. 



Excep- 
tional talent 
unneces- 
sary. 



the normal heart that many modern diagnosticians use two arbitrary 
percussion areas as representing the normal and serving to determine 
and measure any change in the boundaries of the enveloping lung or 
in the size of the heart. (See fig. 14.) 

Apex-beat. — The apex-beat or visible and palpable heart impulse is 
normally found in the fifth interspace, an inch within the midclavicular 
line. 
1 The Heart Valves. — The mitral, tricuspid, aortic and pulmonary 
valves are anatomically located within so small a space that a large 
stethoscope bell will nearly cover them all, but their exact position is oj 
little importance in clinical work. 

The Clinical Valvular Areas. — The points arbitrarily fixed for 
auscultation are: (a). The mitral area which corresponds to the heart 
apex. (b). The tricuspid area corresponding to the lower half of the 
sternum, (c). The pulmonary area corresponding to the second left 
intercostal space at left sternal edge. (d). The aortic area correspond- 
ing to the second right intercostal space at right edge of sternum. 

THE METHODS EMPLOYED IN THE DIAGNOSIS OF 
PULMONARY AND CARDIAC DISEASE. 

The elicitation and interpretation of the physical signs of disease 
depend upon (a). Inspection, (b). Palpation, (c). Percussion, (d). 
Auscultation, (e). Auscultatory percussion, (f). Fluoroscopy and X -Ray 
photography* To a less degree one invokes certain auxiliary methods 
depending upon special procedures or specially devised instruments. 

Prerequisites of Good Work. — Ever}' student and physician should 
thoroughly familiarize himself with the much neglected physical signs 
of health and the nature and extent of individual variation. 

Thoroughness. — Superficial examinations are fatal to reputation and 
prestige. True economy oj time depends upon a correct and systematic- 
technique and method, quick perception, and concentration. As one 
avoids asking the same question twice, so should he try to fix the physical 
signs firmly in his memory, and the well trained man will make a com- 
plete and thorough examination and draw his conclusions, while the 
bewildered blunderer is still skimming the surface. 

Essentials. — A knowledge of topographic anatomy and of the physi- 
ology and pathology of the structure under examination; a good technique 
and a practised hand; good eye-sight and hearing must be combined 

* Mensuration is also used but is of comparatively slight value and 
spirometry and pneumometry are of little use. 



DISEASES OF THE THORACIC VISCERA. 



85 



with an accurate knowledge of the physical signs of health and disease. 
Any one who combines diligence with ordinary intelligence can become 
a skilled diagnostician. 

The Preparation of the Patient. — The chest surface should be 
properly exposed and flooded with a light having its source behind the 
physician who is thus aided in his search for physical signs and his 
study of physiognomy and the play of a patient's emotions, for 
being in shadow, he can avoid betraying surprise, disappointment or 
dismay. Interest, hope, cheerfulness, encouragement and calm are the 
only expressions allowable in the office, wards, or sick room. The arrange- 
ment of the clothing must depend somewhat upon the sex of the pa- 
tient. In dealing with women or young girls it is usually possible to 
conduct a satisfactory examination with some thin, soft garment cover- 
ing the lower portion of the chest. In the male it should always be 
uncovered, and so in the female if any real necessity exists, or if 
by greater exposure some doubt may be resolved.* Certainly no 
proper examination can be made through heavy or starched clothing, 
crepitations in lung apices or heart murmurs being simulated by the 
crackling and rubbing of superimposed material or their conduction lost 
from the same cause. 

Attitude of Patient and Physician. — Whether in or out of bed, a 
patient should, whenever possible, be in an easy, unconstrained position, 
the tissues relaxed and the shoulders square. In the examination of 
the lung apices especially, both face and chest should be squarely to 
the front and the head quiet, otherwise deceptive differences in per- 
cussion, may result from muscular contraction. The physician himself, 
should adopt the easiest and most unconstrained position possible 
for both percussion and auscultation. 

Changes of Position during Examination. — Whenever practicable 
patients should be examined both in the recumbent and erect posture. 
because of the peculiar behavior of certain cardiac murmurs referred 
to further on. 



Good light. 



Physiog- 
nomy. 



Exposure 
of women. 



Exposure 
of men. 

A common 
source of 
error. 



An impera- 
tive rule. 



EXAMINATION OF THE CHEST, WITH ESPECIAL REF- 
ERENCE TO THE LUNGS AND PLEURA. 
INSPECTION. — .1 glance reveals the general contour, nutrition and 
muscular development oj the chest, the symmetry oj the hco sides, equality 
oj expansion, the presence oj sears, skin eruptions or abnormal growths, 

*Such is the confidence placed in professional honor and clean minded- 
nrss that tin- readiness to comply with such requests is usually a measure 
of the woman's refinement ami real modesty. 



The first 
glance. 



M 



86 



MEDICAL DIAGNOSIS. 



Negligible 

factors. 



Slight 
wasting. 



Marked 
deformity. 



Unilateral 
enlarge- 
ment. 

Shrinkage. 



The barrel 
chest. 



Chest of 
forced in- 
spiration. 



The winged 
chest. 




Fig. 19.— i. Unilateral Retraction 
2. Spinal Curvature. — (Gee; modi 
fied.) 



local bulging or retraction and the absence of normal, or presence oj 
abnormal pulsations. 

General Form of the Chest.— Absolute symmetry is unusual because 
of slight lateral curvature of the spine, right or left handedness, or the 
occupation of the individual, and many variations in chest outline are 

trivial and negligible. A slight wast- 
ing oj muscle in the region oj the lung 
apex is ojten more important than some 
gross deformity. The kyphotic scoli- 
otic or scolio-kyphotic deformities need 
no extended discussion but the student 
who has seen markedly deformed per- 
sons come to autopsy will realize the 
importance in diagnosis and prog- 
nosis of the displacement and crowd- 
ing of vital structures. Unilateral changes may be due to vicarious 
emphysema, tumors, effusions, or congenital or juvenile heart disease. 
Unilateral shrinking indicates pleuritic adhesions, cirrhosis, collapse 
or cancer. 

General Deformities. — (Chiefly congenital). Amongst these are 
rachitic chest, transversely constricted 
chest, flattened chest, pigeon breast, 
" trichterbrust " (funnel breast). 

Emphysema. — It should be dis- 
tinctly understood that the barrel- 
shaped chest of emphysema is ordi- 
narily manifest only when the com- 
pensatory curve of the spinal column 
is straightened out by placing the 
patient in a dorsal position. Such a 
chest often appears flattened anteriorly 
when the patient is erect, the shoulders 
being rounded and the "patient slightly 
stooped. The chest outline is that oj 
permanent jorced inspiration, the epi- 
gastric angle being broad, the neck 

short, the stero-mastoid muscles prominent, the ribs unusually rigid and 
the movement more a vertical lifting than a true expansion. 

The "Alar" Chest.— This, also called the ''pterygoid", "paralytic" 
or "phthisical chest," has a small anteroposterior diameter, long vertical 




Fig. 20. — 1. Normal Chest. 2. 
Pigeon Breast. 3. Rickets. 4. Em- 
physema. (Gee; modified.) 



DISEASES OF THE THORACIC VISCERA. 



87 



1 




.big. 21. 
Pigeon breast. — (Rickets.) 



measurement, broad interspaces and narrow epigastric angle. The neck 
is long and slender and the projecting scapulae give it the somewhat 
fanciful name. It does not prove a tuberculosis, but merely suggests 
the condition. 

Various Deformities.— The rachitic 
chest is best exemplified by the pigeon 
breast and the transversely constricted 
thorax indicates the co-incidence of defi- 
cient nutrition and some chronic obstruc- 
tion to breathing in childhood, usually 
naso-pharyngeal adenoids. The line of 
retraction is the line of diaphragmatic 
attachment indicating its close relation to 
imperfect chest expansion. A beading of 
the ribs at the chondro-costal articulations 
is well known as the "rickety rosary". 

" Trichterbrust " (funnel breast) is of 
little importance in diagnosis, though an 
interesting and striking phenomenon. It 
is represented by a groove deepening from above downward and corres- 
ponding to the second portion of the sternum, the ensiform often 
pointing sharply forward. Usually congenital, it may be occupational 
in those who in early life have performed work necessitating contin- 
uous pressure over this region. The 
"thorax en bateau" observed in certain 
cases of syringo-rayelia shows a deep me- 
dian groove in the chest anteriorly. 

Localized Changes in Outline. — 
These are of much more significance than 
general deformities, and marked retrac- 
tion of one side or localized retraction in 
any area nearly always means an old 
pleurisy, fibroid phthisis, past tubercu- 
losis or injury. 

Apex Retraction. — Symmetrical re- 
traction of the apices due to nasal or 
tonsillar obstruction is common, negligible in the absence of physical 
signs and even in adults may promptly disappear after operation. 
Unilateral infraclavicular or suprascapular hollowing suggests existing 
or past disease of the lung or pleura, 




. 22. — Funnel Breast. - 
(Trichter brust). In this 
case congenital. 



Rachitic 
keel-shaped 
and con- 
stricted 
chests. 



Rachitic 
rosary. 



Usually 
negligible. 



Congenital 
usually. 



Usually 
important. 



>vm met- 
rical. 






88 



MEDICAL DIAGNOSIS. 



Chest Measurements. — The life insurance requirements in regard to 
dimension and freedom of expansion are extremely simple. They deman d 
that the circumference of the chest at the level of the armpits shall equal 
one-half the height of the individual in inches, and that the difference be- 
tween full inspiration and forced expiration shall not be less than 2 inches. 
As a test of lung capacity this last requirement is an absurdity, for one 
who cannot expand under proper instruction one-tenth his chest circum- 
ference in inches can hardly be considered normal. In measuring chest 
expansion, one should draw the tape very closely at the level of the 
nipple, especially in fat individuals. Abdominal measurements should 
show the maximum girth with lightly drawn tape and should never 
exceed that of the chest in full inspiration, as statistics show that such 
bow-windowed persons furnish a heavy early mortality.* Marked 
unilateral variations suggest retraction due to fibroid phthisis, pleural 
adhesions or spinal deformity, or, bulging caused by pleural effusions 
and new growths. 

Chest Movements. — Normal breathing is of two types, (1) costal, 
(2), abdominal. The first predominates in corset-wearing women, 
the second in men. That of women is largely superior-costal, that of 
J men inferior -costal and abdominal combined. In normal breathing, the 
ratio of respiration to pulse rate is about as 1-4, its rate is in the newborn 
40-45, at the age of five 22-26, it should be symmetrical, easy and quiet, 
and the two sides of the chest should move equally and synchronously. 
The respiration is best counted by watching the rise and fall of the 
epigastrium, coincident with the action of the diaphragm, or. the upper 
chest of women. If one ostensibly counts the pulse, keeping 
the eye on the proper area, neither clothing nor bed covering pre- 
vents the use of this method nor does the patient's self consciousness 
interfere. (See also Dyspnoea p. 76.) 

Litten's Diaphragm Phenomenon. — This is a phantom shadow of 
inspirator}' rhythm passing downward from the antero-lateral aspect 
of the sixth rib and vanishing just above the costal margin. It corre- 
sponds to the suction exerted upon the intercostal spaces by the separa- 
tion or "peeling off" of the pleural fold coincident with the descent of 
the diaphragm and inferior border of the lung, and its movement should 
range from 2 to 4 inches in the normal chest. To elicit the sign, the 
patient should be placed upon the back facing the light, the shoulders 



Insurance 
require- 
ment. 



An absur- 
dity. 



Use of tape. 



Bow 

windowed 

risks. 



Costal 

vs. 
Abdominal 



Normal 
breathing. 



Counting 
respiration. 



Inspiratory 
rhythm. 



Cause. 



Range. 



* Oddly enough, athletes and consumptives usually show the highest 
figures in chest expansion, because both have been especially instructed 
and the latter practise deep breathing as a therapeutic measure. 



DISEASES OF THE THORACIC VISCERA — PALPATION. 



8 9 




being somewhat elevated. The observer should stand with his back 
to the light, five or six feet away opposite the patient's knees. The 
light should come from one window only, and be not too intense. It 
is readily seen in all normal chests not heavily overlaid by fat, but is Howaf- 
lost or interrupted in pleural adhesion, and absent in effusion, pneumonia disease. 
of the lower lobe or tumors occupying the lower chest and greatly dimin- 
ished in range in incipient or advanced tuberculosis and emphysema. 
On the other hand, tumors or fluid below the diaphragm may not 
entirely obliterate it, and as a differential factor in the diagnosis of 
subphrenic abscess it has not borne out its early promise. 

FLUOROSCOPIC METHODS.— As the descending diaphragmatic 
shadow accurately determines the relative range of excursion of the 
lower border of the lung, this is one of the best methods for detecting 

incipient tuberculosis, a small area of infil- 
tration often checking to a marked degree 
the movement of the affected lung. The 
physician should familiarize himself with 
the range in normal breathing. 

Palpation as applied to pulmonary 
disease has chiefly to do with the detection 
of fremitus, pulsation and lung expansion, 
but also determines the form, consistence, 
extent, mobility and sensitiveness of morbid 
Hfli I growths, the nature of swellings, the pres- 

Fig. 23— Litten's sign, (a) ence j abnormal heat, the location of pain- 

Koduced excursion in pulmo- ' ' *■ 

nary tuberculosis, (b). Nor- f u l areas, the presence or absence of moisture 

mal excursion. . , 

and the quality and elasticity of the skin. 
Respiratory Movements. — In this connection, palpation confirms, 
corrects and amplifies the result of inspection. Expansion of the two 
sides should be uniform, coincident and equal in deep breathing and 
one notes: — (1). Generally increased or diminished movement. (2). 
Unilaterally retarded inspiration (inspiratory lagging). (3). Unilaterally 
retarded expiration (expiratory lagging). The hands are placed fairly 
upon the chest, palm down and the patient sits facing the light while 
the physician views the chest tangentially from behind. Two pencils, 
toothpicks, or matches, placed between the fingers better show the extent 
of movement. For the upper lobe it is well to place the thumbs in the 
supraclavicular space and the lingers in the infraclavicular region. 
General lack of expansion may be due to deficient lung capacity, emphy- 
sema, a rigid chest wall, or a lack of skill on the part of the patient. Mam 




'* Lagging" 

and its op- 
posite. 

Technique. 



Deficient 
expansion. 



J 



9° 



MEDICAL DIAGNOSIS. 



Reversed 
type. 



Epigas- 
trium. 



Tender 
areas. 



Author's 
method. 



Alternating 
palpation. 



Normal 
predomi 
nance. 



Laws of 
fremitus. 

Voice. 

Density of 

structure. 



Reinforce- 
ment. 

Structural 
homogen- 
eity. 



Sound 
dampers. 



persons cannot breathe or cough to order, some do not know how 
to expand their lungs. Unilateral defects of expansion indicate a 
crippled lung, be the cause what it may. Deficient upper-chest expan- 
sion in women, even if bilateral, suggests apical lesions or nasopharyn- 
geal obstruction, for costal breathing is the normal feminine type. 
Superior costal breathing in men should lead one to examine the 
lung bases and abdomen. Any lack of the normal inspiratory fulness 
in the epigastrium, unilateral or bilateral, such as is seen in diaphrag- 
matic paralysis and painful abdominal affections should be noted. The 
breathing of a man who has a painful growth of a movable subdia- 
phragmatic organ is likely to be shallow and of the feminine type. 
In the detection of tender areas, the expression of the face is the safest 
guide. Pleural friction and coarse rales may be palpable. 

Vocal Fremitus. — Vocal fremitus or the vibration of the chest caused 
by the production of sounds at the glottis is best detected by simulta- 
neously placing the ulnar surfaces of both hands upon the chest at 
corresponding opposite points. The patient is then asked to enunciate 
clearly the word "nine," or "ninety-nine," the resultant vibration of 
the chest under the hands being noted and that of one side carefully 
compared with the other. It is a useful procedure alternately to raise 
and lower the palpating hands, thus rendering the contrast in fremitus 
more distinct, or apply the same hand, first to one side and then to 
the other. There is normally a perceptible difference between the 
right and left side, that of the right being the stronger. A marked 
difference is a suspicious sign, especially if the fremitus of the left 
exceeds that of the right side, and even an equality of fremitus should 
suggest a special exmaination of the left apex. Vocal fremitus conforms 
to the laws of sound conduction. In general it follows therefore — i. 
That if bronchial communication exists, the louder and deeper the voice, 
the greater is the fremitus. 2. The denser the conducting material, 
the greater the fremitus, e.g., consolidated lung yields increased fremitus 
provided that it is in contact with, or surrounds a patent bronchus. 
3. The transmission of the sound through a tube and into an air chamber 
causes conservation and reinforcement of the sound-waves and thus 
increases fremitus, e.g., cavity communicating with a bronchus causes 
increased fremitus. 4. The more homoge?ieous the conducting medium, 
the greater is the intensity of vibration (fremitus). 5. The interposition 
of substances of a different molecular structure between the conducting 
body and the palpating hand acts as a damper and interrupts the con- 
duction of vibrations — e.g., absence of fremitus in extensive pleural 



DISEASES OF THE THORACIC VISCERA — PALPATION. 



91 



Increased. 




Immediate 
and medi- 
ate. 



effusion, liquid or gaseous, or diminished fremitus in pleural adhesions. 
This may also be due in a measure to a relaxed condition of the lung* 
The following points are to be borne in mind: — (a). Markedly increased 
fremitus points to consolidation of lung tissue or cavity formation, (b). 
Markedly diminished fremitus indicates emphysema, pleural adhesions, Decreased. 
pleural effusions, pulmonary edema, obstructed bronchus, etc. It must 
not be forgotten that the strength and pitch of the voice and the presence 
of fat and muscle modify fremitus. Also that bilateral increase or 
decrease in corresponding chest areas is, as a rule, of comparatively slight 
significance. 
Pressure Palpation. — By a mere thrusting pressure of the finger 

tips resistance areas may be easily de- 
fined, and the method may be used as 
auxiliary to percussion in outlining 
organs, detecting exudates and large 
areas of infiltration. 

PERCUSSION.— The body may be 
directly struck with the tips of the 
fingers {immediate) or a pleximeter 
such as the finger, an oblong piece of 
hard rubber, or a pencil, may be struck 
by the finger or a percussion hammer 
*^^$S%^^§£- {mediate). It matters little what the 
the e ches fi t nger ™ n0t flatly applied to physician uses as a pleximeter provided 

he adheres to one method, but the linger Fin s er 

' / o pleximeter 

cannot be lost or left behind. The percussion stroke is best made with \ 
the middle finger, and should be given with a loose wrist as if striking a The stroke 
single staccato note on the piano. It is useless to get a special plexor 
and pleximeter, for two pencils, a coin and a pencil, etc., etc., are quite 
sufficient even for the rod pleximeter percussion. Certain matters are 
very important:— (a). The stroke should be equally strong on both sides. 
(b). The pleximeter finger should be placed accurately but lightly upon 
the chest, (c). Exactly the same area on each side should be alternately 
percussed, (d). No change in position Unit involves muscular action 
upon one side should be permitted, (e). The attention should be so con- 
centrated upon the tone elicited as to render unnecessary a prolonged tap- 

*The author is aware that the technique here recommended is not that in 
general use, hut personal experience has convinced him that the use of the 
ulnar surface of the hand is more satisfactory than the employment of the 
palmar surface. 



Vital points 
in tech- 



g2 



MEDICAL DIAGNOSIS. 



Seldom 
needed. 



The best 

usually. 



Valuable. 




ping of the same region and resultant loss of time. (f). The force of the 
stroke should be determined by the nature of the underlying structures. 
(g). The stroke should be perpendicular to the surface percussed. 

Strong percussion is useful when the chest 
wall is very fat or muscular, or when one 
wishes to detect some non -resonant body lying 
beneath one that is resonant, but should be 
avoided when possible as too greatly extend- 
ing the area of vibration. A stroke loud 
enough to be heard throughout a large class 
room is always faulty and the term strong is 
relative and does not mean a pounding stroke* 

Light or moderate percussion is 
generally useful and especially so when one 
has to deal with children, a thin wall, or with 
a non-resonant body overlying a resonant one. 

Auscultatory Percussion. — The combi- 
nation of auscultation and percussion is a 

valuable procedure in competent hands and especially so in deter- 
mining the boundaries of thoracic or abdominal organs and the 
detection of cavities, or the "coin sound" of pneumo-thorax. For 



Fig. 25.- 
This figure shows the condi- 
tions affecting percussion of 
more the normal chest, a. Varia- 
tion in shape and volume of 
the two lungs, b. Modified 
resonance due to ribs and 
sternum overlying pulmonary 
tissue, c. The uselessness of 
percussion near the spinous 
processes of the vertebral 
column. 




Fig. 26.— a. Normal. d. 
Hyperresonance (emphyse- 
ma), b.c. Heavy and light 
percussion over consolida- 
tion. 




Fig. 27. — a. Uulness from 
thick wall. b. Pleural ad- 
hesion, c. Normal, d. New 
growth. 



— r«Hf{ > KlormalReaononee. 

■hHjII — > Increased Resonance 
■4 > Dulne*5. 

the latter it is best practised by the "rod pleximeter" method with 
a small coin and a lead pencil, or, in pneumo-thorax, two coins. The 
stethoscope is placed over the part to be tested or bounded and 

* The nail of the plexor finger should be cut short so that only the pulp 
of the tip meets the pleximeter ringer, and, as in golf, billiards or driving a 
nail, the eye should be fixed upon the exact centre of the pleximeter where 
the impact should come. The finger is by far the best pleximeter for ordi- 
nary purposes. 



DISEASES OF THE THORACIC VISCERA — PERCUSSION. 93 

an assistant percusses lightly with the coin as pleximeter and pencil 
as plexor, gradually receding until a point is reached at which the 
specific note is lost or decidedly changed in pitch and quality. Mere 
decrease of intensity unless abrupt is not reliable. The heart, liver, 
spleen, lung apices, stomach and intestine are quite readily differentiated, 
and, save the two latter, accurately outlined by this method or better Best 
in the author's experience by lightly tapping the surface with the finger 
tips, i.e. combining direct percussion and auscultation. No assistance 
is needed if this method be used. 

Position of the Patient. — For percussion of the anterior surface the position of 
hands should hang loosely at the side; for axillary percussion they should 
be placed upon the head; for percussion of the posterior surface they 
should be lightly folded, not placed upon opposite shoulders.* 

Percussion Sounds. — It is customary to describe the percussion notes Descript- 
as resonant, hyperresonant or tympanitic, dull or -flat. Nothing but lve terms - 
practice will serve to differentiate these sounds but any one may be 
obtained by percussing some portion of the normal body. The typical 
pulmonary resonance is that of the upper axilla, and its pitch, intensity Standard 
and duration should be carefully noted. The dull note is yielded by 
the liver below the lung margin and modified dulness just above this 
point, where only the thin wedge-shaped lung border intervenes. The 
flat note may be elicited by percussing the thigh or the deltoid muscle. Flatness. 
The tympanitic note is yielded by the stomach or intestine, as in Traube's Tympany, 
semilunar space, and an important modification, viz.: — dull tympany 
is heard over the main bronchi or upper sternum. 

Characteristics of the Percussion Sounds. — All percussion notes 
possess certain well-recognized characteristics and percussion itself 
determines resistance as felt by the pleximeter finger. Each sound 
has a certain quality, intensity, pitch and duration Intensity depends intensity. 
upon the energy and amplitude of vibration; pitch upon the rapidity i>; to h. 
of the vibrations, varying with the tension; quality upon the vibrating puaiity 
material and duration upon the strength and amplitude of vibration and Duration. 
the density and tension of the material. Increased resistance goes Resistance. 
hand in hand with dulness and guided by tin's alone a deaf man mighl 
make a very fair percussor. The wore air the organ contains and the Air content. 
greator its deep diameter the more marked is its resonance. 

The Normal Notes. — It is important that the norma! variations 

*The latter position necessarily involves muscular tension that interferes 

with tin- elicitation of the true note. In auscultation, however, this position 
is useful in determining the condition of the interlobar region. 



94 



MEDICAL DIAGNOSIS. 



Apices. 



Infraclav 
icular re- 
gion. 

Primary 
bronchi. 



Hepatic 
area. 



Axillary 
region. 



Clavicular 
percussion. 



Apex per- 
cussion. 



peculiar to different areas of the chest should be held clearly in mind, 
and these stand-ard notes can be learned only by painstaking practice upon 
a sound chest. The apices yield normally a resonant note, clear but not 
intense and tending to rise in pitch (dulness) as the pleximeter finger 
approaches the vertebral line posteriorly, or the trachea anteriorly. 
The infraclavicular space is typically resonant, and the pitch of the 
percussion note is slightly higher upon the right than upon the left 
side. Any tendency to approach the region of a primary bronchus 
results in a note of heightened pitch, increased resistance, and shortened 
duration (dulness). Below the right second rib anteriorly there is 
increased resonance until the fifth rib is reached when the pitch rises 
because of the underlying solid tissue of the liver. At the sixth rib 
resonance ceases and a line of absolute dulness marks the lower limit 
of the lung and the upper border of the uncovered surface of the liver. 
In the axillary region typical pulmonary resonance persists until the 
eighth rib is reached. The cardiac area markedly modifies the per- 




Fig. 28.— Anterior Sur 
face. Lung Borders. 
Forced Inspiration. 




Fig. 29.— Lateral 
Surface. Forced 
Expiration. 



cussion note of the left chest anteriorly from the lower border of the 
third rib downward within the nipple line. Along the whole internal 
boundary of the lung anteriorly the note rises as one approaches the 
sternum. The clavicle is usually used as a pleximeter and directly 
percussed, and its centre yields a markedly resonant note. Internally 
and externally, pitch and resistance rise rapidly, but as a pleximeter 
the author believes it to be fallible and misleading. 

Posterior Surface. — Here the height and mobility of the apices are 
best determined by carrying percussion upward during a forced and held 
inspiration, marking the limit of resonance, and repeating the procedure 
during forced and held expiration. Mere increase of intensity in the 
pulmonary tone in inspiration over that of expiration proves nothing. 



DISEASES OF THE THORACIC VISCERA — PERCUSSION. 



95 



77 is the extension and diminution of the area of resonance that is impor- 
tant. The heavy muscles covering the back make necessary the use of 
greater force and the note is less clear and satisfactory than in front. 
This is particularly true of percussion over the scapula itself and a 
glance at a transverse section of a chest shows the futility of percussion 
near the spine. Passing downward, the superficial liver dulness mark- 
ing the lower border of the right lung is encountered at the ninth rib in 
the scapular line. 

The Lung Borders. — The position and mobility oj the lung borders 





Fig. 30.— Anterior Sur- 
face. Lung Borders. 
Forced Expiration. 



Fig. 31.— 
Lateral Surface. 
Lung Borders. 
Forced Inspira- 
tion. 





Fig. 32.— Posterior Sur-' 
face. Lung Borders 
Quiet Breathing. 



Fig. 33-— Posterior Sur- 
face. Lung Borders. 
Forced Inspiration. 



are affected in every serious chronic disease of the lung. In tuberculosis, 
they show a decided lack of mobility, both at apex and base. In 
emphysema, primary or secondary, pulmonary engorgement and ob- 
structive dyspnoea of any type, they are lower than normal at the base. 
and markedly lacking in range of movement* In fibroid phthisis, 
chronic pneumonia and pleural adhesions the change in position and 

*In vicarious emphysema the loss is less marked. 



Force 

required. 



Liver 
dulness. 



Disturbing 

factors. 



o6 



MEDICAL DIAGNOSIS. 



Relaxed 
tissue. 



movement is a striking symptom. In figures 30 to 33 the respiratory 
changes of the lung borders are clearly shown. It must be borne in 
mind that all sound lungs cannot be held to the same limits, that equality 
of movement as between the two sides is the real test and that a considera- 
ble displacement accompanies mere change of posture. 

High Lung Borders. — The lung maybe crowded upwards or aside 
by pericardial exudates, dilated heart, malignant growths, pleural 
exudates, meteorism, ascites or abdominal tumors. 





Fig. 34. — a. Pleural effusion. 
b. Hyperresonance above 
fluid exudate. c. Normal 
lung. 



Fig. 35. — a. Hyperreson- 
ance over relaxed lung sur- 
rounding tubercular focus. 
b. c. Normal, d. Superficial 
cavity, e. Thick-walled 
cavity. 



Normalftesenonee. 
•ft|j| — > Increased Resonance 
>tf >• Outness. 



PERCUSSION OF THE CHEST IN DISEASE.— Hyperreso- 
nance is heard over distended, relaxed, or emphysematous lung tissue. 
In some cases of senile emphysema it is replaced by a note that is 
distinctly high-pitched and somewhat lacking in resonance. 

Tympany. — The intensity and pitch of a pulmonary tympanitic 
note varies greatly with the size of the cavity in which it is produced, 
the condition of the walls and the size of the communicating bronchus. 
The larger the cavity, the lower the pitch, the greater the size of the com- 
municating opening, the higher is the pitch; and lastly, the pitch of the 
percussion note varies directly with the tension of the walls. 

Skodaic Resonance. — This hyperresonant or tympanitic note is 
heard over relaxed lung tissue, as for example, in pleuritic effusion above 
the level of the fluid, in the neighborhood of an advancing pneumonic 
consolidation, in early edema of the lungs and, to a lesser degree in 
certain stages of incipient apical tuberculosis. In the condition last 
named it may prove puzzling and lead the physician into a futile search 
for a lesion in the less resonant sound lung. 



DISEASES OF THE THORACIC VISCERA — PERCUSSION. 



97 




Fig. 36.— Emphysema. The 
distended air-cells and volum- 
inouslung are clearly shown. 



Tympanitic Note in Pneumothorax.— In open pneumothorax the 
percussion note is extremely drum-like, but it should not be forgotten 
that in many cases of closed pneumothorax the percussion sound is 
distinctly dull because of high tension. The tympanitic quality of any 
note may be lost if tension reaches a certain point. 

Amphoric Percussion Note.— This hollow metallic note indicates a 
large superficial cavity freely communicating with a bronchus and so 
formed as to produce selective reinforcement of vibrations. 

Diminished Resonance.— As reson- 
ance varies directly with the amount of air 
in the underlying structures accessible to a 
percussion stroke, deep-seated areas of con- 
solidation covered by air-containing lung 
tissue yield a mixture of the vesicular and 
dull note. Large areas of consolidation at 
the surface of the lung yield a dulness ex- 
actly like that of the liver. 
Flatness. — This characteristically dead 
or toneless note indicates dense adhesions, liquid pleural effusions or 
solid growths in close contact with the chest wall. The sound is of 
great assistance in differentiating the puzzling cases of pleural effusion 
in which the breath and voice sounds have almost precisely the charac- 
ter of those heard in pulmonary consolidation. It is by no means a 
difficult matter to distinguish between dulness and flatness. 

Special Modifications of the Percussion Note.— The Bruit de pot 
jcle is precisely like the "chinking" produced when the palms of the 
hands are placed lightly together and struck sharply against the knee 
and may be present normally in the thin, elastic chests of crying children. 
In the adult chest it can most readily be obtained in the infraclavicular 
region, if there be a superficial cavity with thin walls and a " slit-like" 
opening. The mouth should be open and the heavy percussion applied 
during expiration. This sign may be present in open pneumothorax, 
in the region of pneumonic areas, or above a pleural effusion. 

Friedreich's Phenomenon. The percussion nolo o\ er a cavity may 
Be higher during deep inspiration than in expiration. 

Wintrich's Phenomenon.— The pitch of the percussion nolo over 
an open cavity is higher when the mouth is open. 

Gerhardt's Sign. -This term is applied to the well known variation 
in the percussion note accompanying change o\ posture and is o\ course 
dependent upon the presence of movable fluid in the vomicus, 
7 



( )jjen 

vs. 

Closed. 



Cavity 



Modified 

vs. 
True dul- 



Growths 

and liquid 
exudates. 



Valuable 
sign. 



I low 
imitated. 



Cavit: 



fechni 



A 



9 8 



MEDICAL DIAGNOSIS. 



Fundamen- 
tal rule. 



Types of 

breath 

sounds. 



Modifying 
influences. 



Broncho- 
vesicular. 



Intensity. 
Cavities. 



Amphoric. 




Biermer's Sign. — In pneumothorax there is a decided change in 
the note corresponding to changes in the patient's position. 

Coin Sound. — This is described under Auscultation, on page 104. 

AUSCULTATION. — The -first law of auscultation demands that the test 
of symmetric breathing shall precede inference — in other words, before 
concluding that a departure jrom the type of 
breathing on one side represents a pathologic 
change, the corresponding opposite area 
should be investigated. Slight symmetric 
departures from the normal are often 
transient and negligible. 

Basis of Auscultatory Phenomena. 
— The art of auscultation rests upon the 
same laws of sound as underlie palpation ( lef J-f : Central a p n e "u m™ n^a 
and percussion. The sound heard when £f & t L he ^£ t ar s fd?wonld 
the ear is applied to the chest is chiefly pro- present the classical signs of 

1 c 1 s 1 complete solidification with 

duced in the glottic Chink, but transmitted patent bronchi. The central 

area of consolidation would 

and modified by the bronchial tubes, lung yield no percussion signs, and 

_, , , ,, rrn ^7 be chiefly denoted by distant 

tissue, and chest wall. The nearer the ear tubular breathing obscured by 
approaches the glottis, the greater is the ^S^S^""" ° f ° ver " 
predominance of a tubular element in the 

sounds heard. If the normal pulmonary structure is replaced by con- 
solidation, the glottic sounds are transmitted almost unmodified. All 
degrees of shading may occur according to the situation of the areas 
of induration and their relation to the bronchi. If the patch of 
thickened lung be remote from the surface, a vesicular sound due to over- 
lying pulmonary tissue will be superadded 
to and modify the tubular sound. Again, 
the larger the bronchus that is in direct 
communication with the iudurated area and 
the more superficial the patch, the more in- 
tense will be the sound. Lung cavities in 
communication with a bronchus yield 
Pleural Effusion, modifications of the same glottic sound, 
and follow the same general law. In 
them we have a definite air-chamber sur- 
rounded by more or less rigid walls of consolidated lung tissue; if, 
then, cavities communicate with an unobstructed bronchus, and are wholly 
or partly empty, and if the communicating tube itself be unobstructed, 
the glottic sounds take on a hollow, metallic or even musical quality 




Fig. 

Especial attention should be 
directed to the compressed 
lung in the larger effusion. 






DISEASES OF THE THORACIC VISCERA — AUSCULTATION. 



99 




Fig. 39— Pneumothorax 
(left); Encysted pleurisy 
[right). 



from the walls of the cavity and thus modified will be transmitted to 
the surface of the chest. 

Interposition of Air or Fluid between Lung and Chest-wall. — 
Any form of pleural effusion, liquid or gaseous, acts ordinarily as a damper 
to transmitted vibrations, hence in any form of pleurisy with effusion, 
breath sounds are likely to be lost below the level of the fluid. Certain 
exceptions to this rule will be considered later. It will be readily 
understood that in the case of pneumothorax a free opening between 
the pleural cavity and lung may be present and that in such a case the 

physical signs would be those of a very 
large cavity. It is hardly necessary to 
point out the fact that the intensity of con- 
ducted sound varies directly as the depth 
and intensity of the voice and inversely as 
the thickness of the chest-wall. 

Mediate and Immediate Ausculta- 
tion. — Auscultation may be either medi- 
ate or immediate at the pleasure of the 
auscultator. 

Mediate. — As to stethoscopes, it matters little what one is used if the 
examiner is competent to interpret what he hears. The chief essentials 
in any stethoscope are: — (a). That it shall clearly conduct sound in 
proper volume from the chest-wall to the ear. (b). That its chest piece 
or bell shall be of a size adequate for the purpose of the instrument, yet 
not loo large or of such a form as to make it impossible to examine thin 
chests or those of children, (c). That the ear pieces are of a form and 
size that will completely close the external auditory canal without 
exerting undue pressure. Many of the modern stethoscopes have a 
diaphragm and are especially useful in auscultatory percussion. The 
author prefers either that of Bowles or of Sansom and uses on all stetho- 
scopes the ear pieces of the latter which are perfectly adjustable, the 
springs being made of malleable metal that can be bent to any degree 
desired. The more complicated stethoscopes have not proven useful 
in the author's hands, nor does he believe that it is wise to use those 
greatly magnifying sound. After all, there is no stethoscope as good 
as the unaided ear, if that has been properly trained. 

Stethoscopic Pressure. — The tyro frequently inflicts much unneces- 
sary pain by forcible stethoscopic pressure, forgetting that only such 
force should be applied as will accurately adapt the whole circumference 
of the bell to the chest wall. In the auscultation of heart murmurs. 



Diminishes 
conduc- 
tion. 



Open pneu- 
mothorax. 



Fat, muscle 
and voice 
strength. 



Essentials. 



Stetho- 
scopes 
advised. 



magnifica- 
tion use- 
less. 



\\ oid 
pressure. 






IOO 



MEDICAL DIAGNOSIS. 



Effects of 

varying 

pressure. 



Quiet deep 
breathing. 



Posterior 

inter-lobar 

region. 



Tubercu- 
lous inva- 
sion. 



" Line of 
march." 

Regions 
most im- 
portant. 



however, it is necessary to alternately increase and diminish the pressure 
by which systolic murmurs are intensified and presystolic murmurs 
diminished. 

Quiet Necessary. — A quiet place is absolutely essential to good 
work, for no matter what form of stethoscope be used, or how con- 
centrated the attention of the physician, outside noise will seriously 
interfere with the work. 

Instruction of Patient. — It may be necessary to show the person 
under examination just how he should breathe, and ordinarily, the lips 
should be closed and the respiration be deep, uniform, regular and 
quiet. Many patients will make one breath much deeper than another, 
or much noisier and the physician is likely to be thus misled. If nasal 
obstruction exists the mouth should be kept open and in any event 
it is well to listen to a few inspirations before applying the ear or stetho- 
scope to the chest. 

Attitude of Patient During Ausculta- 
tion. — The position of the patient during 
auscultation should vary with the different 
areas under investigation, precisely as in 
percussion, save that the most effective ex- 
amination of the region of the posterior 
interlobar space requires that the hand 
should be carried across the chest to the 
opposite shoulder. The scapula is thus 
carried forward and outward, and by its 
posterior border very nearly defines the di- 
vision between the upper and lower lobes. 

Pulmonary Areas Demanding Special Attention. — Fowler, of 
London, has emphasized the necessity for a special examination of certain 
auscultation areas. He shows that tuberculosis nearly always first in- 
volves the apex; not the extreme. tip, but a point nearer to the posterior 
than the anterior surface and somewhat external, and that it follows 
a definite "line of march," passing downward and into the upper portion 
of the lower lobe along the interlobar fissure. Hence the most impor- 
tant areas are: — (a). Posteriorly, at a point opposite the second dorsal 
spine but well toward the scapula, (b). Anteriorly, at, or just below 
the middle of the clavicle, (c). The supra- and infrascapular space. 
(d). Along the inner border of the scapula, when the hand of that side 
rests upon the opposite shoulder, (e). The upper part of the axillary 
space. 




Fig. 40. 



Fig. 40. — An Important Area. 
{After Fowler.) Position for 
auscultation of interlobar re- 
gion. 

Fig. 41. — Selective Points in 
Pulmonary Tuberculosis. 



DISEASES OF THE THORACIC VISCERA — AUSCULTATION. 



IOI 



Vesicular Breathing. — Its characteristics are a peculiar rustling qual- 
ity, low pitch, moderate intensity, and, no definite pause between inspira- 
tion and expiration. The latter has no more than one-third the duration 
of the former and may be inaudible in ordinary auscultation. 

Puerile or Harsh Respiration. — Normal. — In the chest of a child, 
or when listening over a lung that is performing vicarious duties, one 
hears the so-called puerile breathing, which is practically intensified 
vesicular respiration. 

Pathologic. — Over the unaffected lung in .cases of pleurisy with 
effusion or pneumonia. 

Prolonged Expiration. — Aside from the stridor of obstructive or 
spasmodic dyspnoea a respiratory sound possessing this as its most 
marked characteristic is frequently heard on auscultation, and suggests 
at once a difficulty in the expulsion of air from the lungs. If the expira- 
tory note be high pitched, a small area of infiltration is indicated, if 
the pitch be low, then one thinks of distention or relaxation of the lung 
tissue, such as occurs in emphysema, chronic bronchitis, or areas 
immediately surrounding an incipient tuberculous deposit. 

Suppressed Breathing. — Absence of the breath-sounds over any 
part of the lungs indicates either feeble breathing, the interposition of 
some substance between the lung and the chest, or an obstructed 
bronchus. Pleurisy with effusion and pleural growths or thickening 
represent the former, and the rare cases of massive pneumonia, pressure 
of growths or aneurism, or occlusion by foreign bodies the latter. Sup- 
pressed breathing is common at the apex in incipient phthisis and in 
most conditions in which there is collapse of lung tissue. In broncho- 
pneumonia as in early apical tuberculosis, cough, or, in the child, 
crying, may develop well defined breathing or suggestive modifications. 

Cog-wheel Breathing. — Much stress has been laid upon this as a 
symptom of early phthisis. It is over-rated and one should remember 
that mere nervousness produces marked disturbance of the heart's 
action, irregular and unequal inspiration, uneven muscular contraction 
and therefore pseudo cog-wheel breathing. If genuine it should be 
heard even when the breathing is regular and deep, and the heart action 
neither unduly violent nor greatly accelerated. The term "cog-wheel" 
is not descriptive: the breathing is wavy, and marked by distinct breaks. 
When genuine it indicates imperfect expansion of some portion of the 
lung. 

Bronchial Breathing. -Xonnal.—U a stethoscope be placed over 
the seventh cervical spine bronchial breathing is heard. It differs from 



Normal 
breathini 



Children. 



Suggested 
ailments. 



Ailments 
suggested 



Effect of 
cough. 



Usually 

misleading. 



Precau- 
tions. 



Normal 
over :th 
cen ical. 



MEDICAL DIAGNOSIS. 



Qualities. 



Points to in- 
filtration or 
compres- 
sion. 



Misleading 
variation. 



Normal 
area. 



Points to 
deep con- 
solidation. 



Glottic 
breathing. 

Superficial 
consolida- 
tion. 



Hollow 
and low- 
pitched. 




vesicular breathing in almost every particular. Both inspiration and 
expiration are high pitched; between them is a distinct interval. Expira- 
tion is greatly prolonged, its intensity being equal to or even greater than 
that of inspiration. 

Pathologic. — Such breathing indicates consolidation or compression 
of lung tissue in close relation to a patent bronchus. Thus it is heard 
in pneumonia and phthisis, and over lung compressed by mediastinal 
or other tumors or pericardial effusion. 
For the same reason .probably, the voice 
and breath-sounds are well conducted in 
some cases of effusion but in such the 
flat toneless percussion note suggests the 
correct diagnosis and the breathing is 
usually distant though tubular. 

Broncho-vesicular Breathing. — 
Normal. — If the stethoscope be placed 
over the second intercostal space at the 
sternal border, or upon the upper inter- 
| scapular region of the normal chest, the 
sound conducted to the ear is a curious 
mixture of vesicular and bronchial breath- 
ing. 

Pathologic. — There is no more import- 
ant clinical study than this modification, as it frequently represents 
early tuberculosis or deep-seated central consolidation. 

Tubular Breathing. — Normal. — Tubular breathing is heard nor- 
mally over the glottis and differs from bronchial breathing in being more 
intense and possessing a peculiar whiffing quality. 

Pathologic. — Its significance when heard over pulmonary areas is 
found in its association with complete superficial consolidation of lung 
tissue. It is important that this breathing should be carefully studied, 
because of its intimate association with, or near likeness to cavernous 
and amphoric breathing. 

Cavernous Breathing. — The sole important difference between cavern- 
ous and tubular breathing lies in the fact that in the former the pitch is low 
and the quality distinctly hollow. For its production, a pulmonary 
cavity is necessary, empty or partially so, and not less than an inch 
(2 cm.) in diameter. 

Amphoric Breathing. — Amphoric breathing is exactly the same as 
cavernous, save that it possesses a metallic or musical quality, the sound 



Fig. 42.— Malignant Growth 
(left) and Pulmonary Abscess 
(right). The larger mass on the 
left side involves a bronchus, 
and would yield signs of con- 
solidation. The anterior super- 
ficial mass would present only 
dulness, diminished voice and 
breath sounds, with defective 
lung movement on affected 
side. Such abscesses as are 
here shown present few recog- 
nizable physical signs, and are 
often overlooked. 



DISEASES OF THE THORACIC VISCERA — AUSCULTATION 



IO,3 



resembling that produced by blowing across the mouth of an empty 
bottle. It is heard over large superficial cavities, and in open pneumo- 
thorax. In all cases of cavity jree bronchial communication is necessary 
to the production of the typical sound. 

Vocal Resonance. —Normal. — If the ear or stethoscope be applied to 
the axillary region of a healthy chest, and the patient slowly repeats 
the word "ninety -nine," the voice is heard but the words cannot be 
distinguished; moreover, the ear recognizes the fact that the sound is 
produced at a point some distance from the stethoscope. Such normal 
vocal resonance is associated with a vesicular murmur and a normal 
percussion note, but in disease we find variations to fit every variety of 
abnormal breath-sounds and percussion tones. 

Bronchophony (bronchial voice). — Normal. — Bronchophony may be 
heard in the normal chest over the manubrium. At this point the 
voice or whisper seems to be directly at the mouth of the stethoscope 
and the sense of remoteness, so marked in normal resonance, is alto- 
gether lost. Pathologic. Bronchophony is heard in varying degrees 
under the same conditions that produce bronchial and bronchovesicular 
breathing. A faint bronchophony is sometimes termed a "bronchial 
whisper" but should be called "distant" or "faint" to avoid confusing 
it with "whispered" bronchophony. 

Pectoriloquy (tracheal voice). — Normal. — Pectoriloquy corresponds 
to the normal voice as heard over the trachea. It differs from bron- 
chophony in that the words seem to be distinctly articulated and spoken 
directly into the ear. Whispered pectoriloquy is the term applied when 
the whispered voice is thus transmitted. 

Pathologic. — It is heard over superficial cavities and consolidation. 

Increased Vocal Resonance of Heightened Pitch. — Vocal reso- 
nance may be only slightly increased, with a rise in pitch in cases of im- 
perfect consolidation of lung tissue, or in cavities that are not sur- 
rounded by consolidated lung tissue. 

Egophony. — Pathologic. — Egophony is a peculiar modification of 
the voice-sound that gives it a bleating or distinctly nasal character. 
It is most frequently heard at the upper level of pleuritic effusion, ami 
just above the area of advancing consolidation in pneumonia. Attention 
is not infrequently directed to small pleural effusions, acute or sub- 
acute, by encountering egophony at the inferior angle of the scapula. 

Diminished Vocal Resonance. — The following conditions result in 
diminution or loss of the normal vocal resonance: 

Normal, (a). Weak voice, (b). Excessively thick wall. Patko- 



Metallic 

and musical 

cavities. 



Where 
heard. 



Character- 
istics. 



Modified in 
disease. 



Where 
heard. 



Peculiar 
features. 

Indicates 
consolida- 
tion. 



Where 
heard. 



Superficial 

lesions. 

Important 
variation. 



SiLrniti- 
cance. 



+ 



104 



MEDICAL DIAGNOSIS. 



logic, (a). Emphysema or relaxed lung from whatever causes, (b). 
Effusion into pleural cavity (liquid or gaseous), (c). Pleural growth 
or thickening, (d). Massive pneumonia (large bronchi blocked), 
(e). Occluded bronchus due to foreign bodies or to pressure. 

Echoing Resonance. — The coin sound proper is a peculiar bell -like 
note heard over the affected side in pneumothorax when a coin is placed 
upon the chest and lightly struck with another. The auscultator 
usually applies his ear or stethoscope to the back and an assistant 
manipulates the coin upon the anterior surface of the chest. Echoing 
or amphoric resonance of the voice and heart-sounds may be heard under 
similar conditions. 

RALES. — Rales are either dry or moist, and a consideration of the 
anatomic structures of the lungs and pleura makes it easy to understand 
the mode of their production, their significance and the varying qualities 
dependent upon the condition of the lung itself and the character of 
; the respiration. Aside from the friction rale, dry rales may be divided 
into two groups: — (a). Sibilant or whistling, (b) Sonorous, "at one 
time resembling snoring, at another the sound of a bassoon, and very 
frequently it is like the cooing of a turtle-dove. " They are of all grades 
of pitch and intensity and in passing from the very feeblest sibilant to 
the most raucous sonorous rale, the differences depend upon the size oj 
the tube in which they are produced, its proximity to the surface, rela- 
tion to the consolidated areas, and the depth and character oj the respi- 
ration itself. Such rales alone or in association with others are 
most frequently found in bronchial obstruction, bronchitis, asthma and 
emphysema, but persistent dry rales are common in incipient tubercu- 
losis and may be distinctly resonant or consonating. 

Stridor. — Stridor is the loud sound heard over the trachea or a primary 
bronchus that is obstructed by aneurism, tumor or a foreign body. A 
similar sound is heard in paralysis of the abductors, such as may result 
from pressure upon the recurrent laryngeal nerve. 

Moist Rales. — In the consideration of moist rales the chief points to 
be noted are: — their quality, size, pitch, and resonance. A moist rale 
may be produced by respiration at any point from the glottis to a terminal 
alveolus and may be due to the serous exudate of edema, the mucous or 
mucopurulent secretion of bronchitis, the thick tenacious sputa of pneu- 
monia, or the purulent fluid of a pulmonary cavity or pneumo-pyothorax. 
Being oftentimes associated with consolidation of all kinds, or cavity 
of any degree, it must vary in pitch, quality, size and intensity with its 
surroundings. 



Pneumo- 
thorax. 



Amphoric 
voice and 
heart 
sounds. 



Dry and 
moist. 



Sibilant 
and sonor- 
ous. 

Musical. 

Modifying 
factors. 



Obstruc- 
tion or glot- 
tic paraly- 
sis. 



Cardinal 
points. 



Sites. 
Cause: 



DISEASES OF THE THORACIC VISCERA— RALES. 



I05 



Crepitation. — Beginning with the smallest rale we have crepitation, 
a shower of tiny sounds compared to the crackling of burning salt, or 
better to that produced by rolling a lock of hair in the fingers, held close to 
the ear. Crepitation is not a liquid rale but signifies merely that air is 
entering into a collapsed vesicle, or, represents fine pleural friction or the 
separation of slightly adherent pleural surfaces.* It is one of the early 
signs of lobar pneumonia (crepitatio indux), hemorrhagic infarction and 
incipient tuberculosis; occurs as a precursor of resolution (crepitatio 
redux) and may normally be heard at the apex or base of the lung when 
the first deep inspiration is taken. Such rales are also heard persistently 
at the base of the lung early in pulmonary edema and hypostatic 
congestion. They are heard always at the end of deep inspiration 
and may be confounded by the tyro with superficial pressure crepitation 
produced by his own ear or stethoscope. 

Crackling Rales. f — Three varieties of crackles are recognized by 
the diagnostician. The fine crackling or subcrepitant rdles are produced 
in the finer bronchi, heard chiefly but not exclusively in inspiration and 
indicate, as a rule, commencing infiltration. Heard at the apices, they 
always strongly suggest an incipient tubercular process; at the base, 
pneumonia or congestion. They are heard early in resolving pneu- 
monia. Medium crackling rales are of the same general nature as the 
foregoing, but coarser. They are heard over softening tuberculous 
areas, broncho-pneumonia, and resolving lobar pneumonia. Conso- 
nance is marked in the presence of infiltration. 

Large, Crackling Rales are still coarser and more distinctly fluid 
than the foregoing and point usually to extensive softening in a tubercu- 
lar area. 

Mucous Click. — This sound stands midway between the crackling 
and the bubbling or gurgling rales. It is a "sticky," mucous crackle 
usually single and commonly heard at the apices in tuberculosis. 

Bubbling Rales. — These may be small, medium or large liquid rales, 
and are usually readily recognized. Gurgling Rales. — These are 
usually heard over large cavities during cough or in forced inspiration. 

Pitch and Resonance of Rales. — All varieties of rales have a 
certain pitch and degree of resonance, directly attributable to their surround- 
ings. One that is produced in a bronchus or cavity surrounded by 

* There is certainly a pleural crepitation hardly distinguishable from 
alveolar crepitation and, a more pronounced pleural crackle. 

1' The author believes that the ear distinguishes easily a difference between 
medium or even large crackles and the similiar but more Liquid " bubbling " 
rales. Hence tin- classification used. 



Smallest. 



Dry rale 
Cause. 



Associated 
lesions. 



When 
normal. 



Source of 
error. 



Signifi- 
cance. 



Conso- 
nance. 



io6 



MEDICAL DIAGNOSIS. 



consolidated lung tissue or atelectasis will have many of the qualities 
of tubular or amphoric breathing hence we speak of resonant rales, 
echoing rales, consonating rales, etc., and these may be either moist 
or dry. There are certain special sounds of great interest, and chief 
among these are "post-tussive suction," "metallic tinkling" and "suc- 
cussion." 

Post-tussive Suction. — This interesting physical sign is pathog- 
nomonic of cavity formation and has been aptly termed "the india- 
rubber-ball" sound. It is supposed to be due to the expansion of a 
collapsed thin-walled cavity communicating with a bronchus. A 
similar but coarser and gurgling suction sound either inspiratory or 
expiratory may be heard in pneumothorax if communication with the 
lung exists. 

Metallic Tinkling. — This term is applied to the beautiful musical 
sound sometimes heard over a very large cavity with dense smooth 
walls or in pneumothorax. The phenomenon is really due to the 
production of echoes, and when low pitched is often termed amphoric 
tinkling. 

Hippocratic Succussion. — This is the well known swashing sound, 
often metallic, produced by the somewhat heroic measure of shaking 
the victim of a pneumohydro- or pyo-thorax. 

Friction Sounds. — True friction is produced by the attrition of pleural 
surfaces roughened by inflammation and is usually unmistakable, often 
palpable. The quality of the sound is creaking, rubbing or crackling;* 
it is ordinarily distinctly superficial, commonly best heard in the 
axillary and inframammary regions and at the anterior lung margins, is 
usually double in rhythm, and what is still more important, is associated 
in most cases with pain on deep inspiration and is tcnaffected by cough. 
Friction rales may persist at the margins of dulness due to pleural exu- 
date and their reappearance indicates absorption. Pleural crepitation 
usually occurs early in the inspiratory phase of the individual breath- 
sound whereas true crepitation is late but the distinction is not always 
possible. 

THE USE OF THE X-RAY IN THE EXAMINATION OF THE 
CHEST. — The importance of fluoroscopic and photographic methods in 
the diagnosis of diseases of the heart, lungs and pleura is too little appre- 
ciated by the average physician. Fluoroscopic examination has been 



Resonant 
and conso- 
nating 
rales. 



India rub- 
ber ball 
sound. 



Water 
whistle 
sound. 



Cavity or 
pneumo- 
thorax. 



Pneumo- 
thorax. 



Invaluable 



L 



* It is accurately simulated by the sound heard when the palm of the 
hand is pressed firmly against the ear and the dorsum rubbed by the fiat 
of the finger pulp. 



DISEASES OF THE THORACIC VISCERA — X-RAY. 



107 



made a part of the author's routine method for several years, and has 
proven itself indispensable. Either the static machine or the coil may be 
used, the former having as its sole advantage its applicability to therapeu- 
tic uses; the coil being much more convenient on account of its greater 
reliability and the short time needed to put it in operation. Full 
instruction regarding technique is to be found in books devoted especially 
to that subject, and it need only be stated that, (a), tubes of medium 
resistance give the best results, (b). That minimum exposures should be 
used. (c). That repealed exposure at short intervals should be avoided 




Fig. 43.— Advanced Pulmonary Tuberculosis. Multiple cavities at 
apices. One at right base. Infiltration marked. Compensatory em- 
physema with intermingled infiltration at left base. 

so jar as possible, (d). That especial care should be observed in the 
case of patients having an irritable or diseased skin. (e). That the 
same focal distance should be observed in every case. This is ordinarily 
15 inches from the target to the surface of the body. This precaution 
is especially necessary for the accurate comparison of observations, (f). 
A thorough familiarity with the fluoroscopic appearances of the normal 
chest is indispensable, (g). The operator must, by the use of a proper 
screen, avoid the exposure of his own hands, or be prepared for minor 
burns which may prove extremely troublesome, (h). A negative will 
often show more than the fluoroscopic picture or finished photograph. 
By this method of examination areas of pneumonia, of tubercular 



Static 

vs. 
Coil. 



General 
rules. 



Beware of 
burns. 



I 'so one 

focal dis- 
tance. 



Know the 
normal. 



Value of 



A 



io8 



MEDICAL DIAGNOSIS. 



Lesions 
shown. 



infiltration, of pleuritic adhesion and existing pleuritic effusions may be 
detected. While the X-Ray is but a part of a physical examination 
one is surprised to find how often ordinary physical signs have been 
misleading or have failed to reveal more than a part of the conditions 










Fig. 44. — Aneurism of ascending and transverse portions of arch, classical 
signs absent. Death six months later from rupture into pericardium. 



periorto actually existing. Often an apparently slight tuberculous infiltration 

physical i s found to have involved the major part of the lung, an apparently 

small heart proves a dilated one, and quite often one finds a 



DISEASES OF THE THORACIC VISCERA — COUGH. 



109 



seemingly unilateral involvement bilateral. An unsuspected cavity 
may show plainly as a bright reflex. In diseases of the heart the X-Ray 
methods are invaluable, for not only is the cardiac outline clearly and 
accurately denned, but the early diagnosis of aneurism or mediastinal 
growths is made possible. Indeed, it is the only method by which a 
positive diagnosis oj aortic aneurism can be made in its early stages. 
The outline of the distended aorta is plainly shown, and what is quite 
as important, expansile pulsation, the sine qua non of diagnosis is made 
evident. 

Fluoroscopic Signs and Their Significance. — Bright light reflex 
in shadow areas = cavity. Apical shadows = infiltration usually tu- 
berculous. Shadows at base — pneumonia, congestion, adhesions or 
edema. Unilateral shadow associated with rhythmic lateral displace- 
ment of the heart in deep breathing = pleural effusion. Same unasso- 
ciated with such displacement .= old pleural adhesions, malignant 
disease or subdiaphragmatic abscess. Localized shadow may indicate 
abscess or malignant growth, localized tuberculosis, foreign bodies, 
encysted pleurisy. The clinical symptoms aud physical signs of course 
indicate the acute, chronic, primary, or secondary nature of the lesion. 

COUGH. — The term cough covers single or multiple, consecutive, ex- 
plosive, expiratory acts preceded by a spasmodic glottic closure. It may 
arise from a multitude of causes and the irritation of widely separated 
and diverse regions, though commonly purposeful and intended to re- 
move irritating material from the bronchi or throat, this being ordinarily 
the secretion accompanying acute or chronic disease of the air passages, 
or, foreign bodies. The most sensitive regions are the interarytenoid 
space, the tracheal bifurcation, pharynx, base of the tongue, naso- 
pharynx and certain areas in the nasal passages proper. Many forms 
of reflex cough are observed and these should always receive considera- 
tion in instances of otherwise inexplicable persistent cough. Arnold's 
branch of the pneumo-gastric nerve is accountable for a rare cough 
connected with irritation of the external auditory canal.* So also 
chilling of the surface, pressure upon the spleen or liver, or the various 
diseases of the liver or gall-bladder when associated with involvement 
of the diaphragmatic pleura; and finally, in women, chronic disease of 
the pelvic organs, is an occasional cause and such a cough frequently 
disappears entirely after operation. Other coughs are purely neurotic, 
such are the obtrusive hysterical cough and the barking cough, of pu 



Incipient 
tuberculo- 



Heart 
lesions 



Aneurism. 



Definition. 



Diverse 
causes. 



sensitive 

areas. 



Reflex 

cough. 



Neuroti 
cough. 



♦Such a case recently observed by the author was promptly 
manently relieved by the removal of impacted cerumen. 



and 



per 



ilEDICAL DIAGNOSIS. 



Stomach 
cough. 



Smoker' 
cough. 



Xasal 
cough. 



Pleural 
cough. 



Source of 
error. 



Character- 
istics. 



Sup- 
pressed. 
Paroxys- 
mal. 



Reflex. 
Vomiting. 



Hacking 
cough. 



Barking, 
hollow and 
brazen 
coughs. 



berty. Dentition cough in infants is purely reflex in character, but the 
so-called stomach cough, associated ordinarily with chronic gastritis and 
most frequently observed in drinkers is no doubt due to the accom- 
panying pharyngitis and the same statement applies to the smoker's 
cough and its associated laryngitis. Many cases of excessive irritation 
of sensitive turbinate areas are observed, particularly in young people 
and neurotic individuals, the conditions being very similar to those as- 
sociated with asthmatic paroxysms and hay fever. It should be remem- 
bered that irritation of the lung parenchyma does not cause cough, but 
unquestionably irritation or inflammation of the pleura does, hence in 
pulmonary disease, acute or chronic, the cough is attributable either to 
bronchial or pleural irritation. Again it should be said that the assump- 
tion that any cough is reflex or neurotic should be postponed until all 
other channels have been thoroughly investigated. 

Dry and Moist Cough. — In incipient phthisis and the early stages 
of bronchial inflammation or irritation from whatever cause the cough 
is unproductive, hence it is termed dry. It may be extremely urgent, 
paroxysmal, or painful. Acute bronchitis, pneumonia, whooping cough, 
asthma, and pleurisy furnish the best examples, and, in their early 
stages, practically all of the nervous, reflex, or pressure coughs are dry. 
When pain is present an effort is made to suppress the cough as is the 
case especially in lobar pneumonia and pleurisy. Paroxysmal cough 
best exemplified by whooping cough may be encountered in a large 
number of conditions whether due to direct irritation as in the case of a 
laryngeal tumor, or to reflex causes as in impacted cerumen or tumes- 
cence of the nasal passages, and in pertussis particularly this paroxysm 
, may be associated with vomiting and even with hemorrhages under the 
skin and epistaxis. A paroxysmal cough may also be associated with 
the accumulation of secretion and attended by a profuse and perhaps 
sudden discharge, as for example, in bronchiectasis, certain pulmonary 
cavities or the rupture of abscesses into the bronchi. Pressure cough 
due to mediastinal tumors, pericardial effusion, etc., may be, but ordi- 
narily is not," "paroxysmal. The so-called hacking cough is especially 
common in incipient tuberculosis, but may occur in chronic catarrh of 
the upper air passages. 

Various Types. — Barking cough, if not neurotic, is usually asso- 
ciated with inflammation of the glottis, a hollow cough with advanced 
tuberculosis, and ringing, metallic or brazen cough with mediastinal 
pressure" from whatever cause. The author has observed as good ex- 
amples in massive pericardial effusion as from its commoner cause, 



DISEASES OF THE THORACIC VISCERA — SPUTUM. 



Ill 



Emphy- 
sema. 



Toneless 
coutrh. 



Ominous 
sign. 



Sources. 



aneurism. In emphysema the cough is peculiar and somewhat charac- 
teristic in the prolongation of the individual expirations and the mani- 
fest forcing and prolonging of the series. The hoarse cough of croup (roup. 
is well known and a noiseless cough may occur in certain forms of 
glottic paralysis or a toneless cough in terminal cases of pulmonary 
disease. 

The inspiratory whoop may follow various forms of paroxysmal cough w hooping, 
but is occasional and unusual, whereas in whooping cough when devel- 
oped it is persistent and practically pathognomonic. Finally, the ab- 
sence or cessation of cough, with persisting physical signs, may indicate 
profound toxaemia, excessive weakness or approaching death and is 
seen especially in fatal pneumonias of infancy, childhood and old age. 

Localized momentary protrusion normally occurs in the apices and 
upper intercostal spaces during cough. The condition is exaggerated 
in emphysema and diminished in infiltration. 

SPUTUM. — The sputum proper is that secretion of the air passages 
obtained by "hawking" or coughing and must include nasal, pharyn- 
geal, laryngeal, bronchial, alveolar, and a certain amount of oral secre- 
tion. All save that representing pure pus or blood is mucoid in con- 
sistence and the general term embraces all similar material derived 
from fistulous communication with adjacent structures, or destructive 
processes within the respiratory tract, i.e. perforating abscess, echino- 
coccus cysts, cavities, etc. One must observe (a). Reaction, (b). Color 
and transparency, (c). Air content, (d). Consistence, (e). Amount, (f). 
Odor. (g). Albumin content, (h). Microscopic findings. The reaction 
is alkaline save after certain decomposition processes outside the body. 
Aside from misleading tints derived from food or medicines the color 
varies from the colorless mucoid or serous sputum to that of pure blood. 
Slight purulent admixture (muco -purulent sputum) or predominance 
of pus (purident) produces various degrees of yellow or greenish yellow. 
Dust and soot inhalation gives a dingy or grayish tint and bile pigment 
or the development of certain germs may produce a faint or even vivid 
green. Blood may be pure or represented only by faint pink, light Blood. 
brown or salmon color, iron rust shading, faint yellows and greens or the 
thin serous so-called "prune juice" sputum. True icteric sputum appears 
only when actual jaundice or perforating hepatic abscess is present 
though many blood containing specimens of unusual tint react to the 
test for bile pigment. Greenish tints may occur in carcinoma, chloroma 
and various other conditions, and various occupational sputa are en- 
countered as in mirror polishers, aniline dye workers and others. In 



Data. 



Bile 



^ 



112 



MEDICAL DIAGNOSIS. 



Important 
varieties. 



Striking 
differences. 



Spirals. 



Plugs. 



Food 

particles. 



Fibrin. 



Fluidity 

vs. 
Viscidity. 



disease of the mitral valve with brown sputum peculiar pigment holding 
cells are present; in the perforating abscess of amoebic dysentery the 
"anchovy sauce" sputum may be encountered, and in hysteria there is 
occasionally a viscid or jelly-like sputum exactly like crushed raspber- 
ries, which may create much unnecessary alarm. 

Air Content. — Foaminess and low specific gravity, indicate the air 
content and all serous sputum is frothy. Cavity sputa appear in 
water as globules, flattening to coin like bodies (nummular sputum) as 
they sink to the bottom, and in general, the greater the pus content the 
less the air, and the smaller the tubes of origin the greater the air con- 
tent. In bronchiectasis and gangrene one finds three distinct layers 
because of the varying specific gravity. 

Consistence. — A proper background is readily obtained by laying 
a piece of glass or a Petri dish over black paper or cloth or purchas- 
ing or making a special plate with half its sur- 
face pure black. One may find (a). "Cursch- 
mann , s spirals," which are not pathognomonic 
of asthma, but most frequent in that disease. 
They are refractile and visible to the naked eye, 
represent a bronchiolitic exudation (Sahli), are 
interesting, but have no great diagnostic import- 
ance. u Ditlrichs plug's" are yellowish white 
and mustard seed sized, foul smelling aggrega- 
tions of fatty acid crystals and bacteria closely 
resembling the tonsillar plugs of follicular tonsillitis and are found in 
decomposition processes (pulmonary gangrene, foul cavities, etc.). 
Misleading food particles are usually starchy and strike a blue color 
with Lugol's solution. Fibrin masses are white and extremely tenacious 
and are rendered clearer and bulkier by the addition of acetic acid. 
They vary in size from the tiniest plugs to the fibrinous casts of the 
bronchial tubes (croupous pneumonia, fibrinous bronchitis), or the 
diphtheritic membrane. The fibrinous casts show best if shaken up 
in water. Rarely and especially in old cases of tuberculosis, calcareous 
plugs often of considerable size are expectorated,* or various foreign 
bodies of recent or ancient introduction may appear. Pus content or 
serum determines the fluidity and mucous and nuclein (croupous pneu- 
monia) the viscidity and tenacity of the sputum. All sorts of sub- 




Fig. 45-— Curschmann's 
Spirals. A. unmagnified. 
B. magnified. 



* In a case observed sometime ago a large lung stone was ejected after a 
protracted and violent coughing seizure and no symptom of the old disease 
had been manifest for over 20 -cars. 



DISEASES OF THE THORACIC VISCERA — SPUTUM. 



"3 



Best cups. 



stances may be introduced by fistulous communication with abscesses, 
echinococcus cysts, etc., etc. 

Amount. — Whenever possible the 24 hours sputum should be obtained 
and the transparent sputum cups are far better than the metallic and 
paper cups so generally used. Early stages of inflammation yield 
scant secretion. The morning is the most productive period in chronic 
processes though in pulmonary cavity and especially bronchiectasis 
large amounts may be raised at irregular times, often when assuming a 
special posture. Advanced pulmonary tuberculosis, bronchorrhcea, 
bronchiectasis, perforating abscesses, pulmonary edema and resolving 
pneumonia furnish large amounts. 

Odor. — Ordinarily odorless when first raised it may be foul in any 
process attended with decomposition within the lung (bronchiectasis, 
certain tuberculous cavities, abscess of liver, communicating empy- 
ema) and characteristically so in gangrene. 

Albumin Content. — The albumin content constitutes a rough 
measure of the severity of an inflammation hence some slight value 
may be attached to a decided percentage as differentiating simple 
bronchitis from pulmonary tuberculosis.* 

Microscopic Findings. — The sputum should first be examined as a 
flat preparation without staining and then by making a smear, drying 
in the air and staining for three minutes with Wright's stain, thoroughly 
washed, and mounted. One may find (a). Flat pavement cells from the 
mouth and pharynx, (b). Columnar ciliated cells from the larynx, 
trachea and bronchi, (c). Mono or polynuclear oval cells (25-50 y.) 
from the alveoli which may contain (1). Irregular highly rejractile masses | I 
of myelin showing concentric layers. (2). Blood pigment bearing (heart 
disease) cells. (3). Hematoidin crystals. (4). Fat. (5). Carbon, (d). Free 
myelin bodies, (e). Elastic fibres. These if present may be found 
by pressing a cheesy, granular or thick portion of sputum between 
two glass slides and using a low power lens.f They indicate actual 
destruction of lung tissue, most frequently advanced tuberculosis, anil 
usually show the alveolar arrangement. Staining is quite unnecessary . 
the only difficulty being the possible derivation of the fibres from retained 

*To test sputum for albumin Sahli presents Wagner's method, viz. : — 
Treat with 30% acetic acid and shake thoroughly to precipitate mucin, 
filter, wash, treat filtrate with NaOII until nearly neutralized and test iov 
albumin by heat, potassium ferrocyanide or Esbach's method. 

f Boiling equal parts of sputum and 10% Xa O H or KOI 1. setting aside 
for 24 hours and then examining selected portions of the precipitate is a 
useful device and search is seldom successful without it. 

8 



Slight 
value. 



Stain. 



Cells. 



Crystals. 



Klastic 

tissue. 



ii 4 



MEDICAL DIAGNOSIS. 



Blood 

cells. 



Crystals. 



Bacteria. 



Tubercle 
bacillus. 



Thinning. 



Centrifugal 
method. 



Stai 



food in specimens not properly safeguarded in collection. Owing to 
he presence of a peculiar ferment they are often absent in pulmonary 
gangrene, (f). Leucocytes. Eosinophiles are abundant in asthmatic 
sputum and neutrophiles in all sputa. They may show phagocytic 
inclusions of fat, carbon or hematoidin. (g). Erythrocytes. Micro- 
scopic blood exists in most sputa associated with cough of any marked 
degree, but macroscopically it is present only in violent paroxysmal 
cough, accidental hemorrhage and true inflammatory or necrotic proc- 
esses. Fibrin if present may be demonstrated by Weigert's method. 
(G). Crystals. The rhomboidal crystals of cholesterin indicate emphy- 
sema or lung abscess, seldom phthisis. The sharp slender fasciculated 
fatty acid crystals suggest gangrene or advanced tuberculosis, while the 
colorless, octahedral Charcot Leyden crystals point to bronchial asthma. 
Yellow or brown amorphous masses or rhomboidal crystals of hema- 
toidin point to blood retention and ulceration within the alveoli, and leucin 
and tyrosin may be present in emphysema, (h). Bacteria. Among 
those occurring in sputum are: — tubercle bacilli (and its simulators 
the smegma and timothy bacilli) and those of pneumonia, anthrax, 
influenza, typhoid, glanders, plague and leprosy as well as the Fried- 
lander bacillus, micrococcus tetragenous and others. The tubercle 
bacillus is by jar the most important and for its determination most 
careful work and even animal inoculation may be necessary. In most 
instances it is easy to find the germ in the cheesy particles or "thicker 
portions of a specimen, but at other times they must be obtained by cen- 
trifugalization of the sputum. 

To Procure a Concentrated Sediment. — Take of sputum one part, 
distilled water ten parts and stir in repeatedly while boiling a few drops of 
sodium hydrate solution (io)% — when practically homogeneous the 
mixture may be directly centrifuged and examined — but it is much 
better to add a few drops of a phenolphthalein solution and add acetic 
acid drop by drop, while stirring, until only a faint pink remains. The 
resulting sediment may then be centrifuged and examined, some of ihe 
original sputum being mixed with the sediment to secure better fixation 
in the staining process. The bacilli are often readily found in sputum 
thinned by spontaneous decomposition. 

The stain commonly used is the Ziehl-Neelsen (saturated alcoholic 
solution of fuchsin or gentian violet added drop by drop to 5% solution 
of carbolic acid until a surface sheen appears) which keeps indefinitely 
as does Czapelewsky's solution (1 gm. fuchsin to 5 c.c. of liquid carbolic 
acid, add 50 c,c. of glycerine stirring thoroughly and finally add 100 c.c. 



DISEASES OF THE NOSE, PHARYNX AND LARYNX. 



"5 



Best 

method. 



of water). To eliminate the less resistant smegma or timothy bacillus 
the specimen should be thoroughly decolorized by Czapelewsky's 
method and Ebner's fluid (hydrochloric acid gms. 2.5, sodii chloride 
2.5, distilled water 100, alcohol 500), or by Pappenheim's solution which 
not only decolorizes the smegma bacillus but stains it blue (absolute 
alcohol 100 c.c.+ i gm. corallin+ methylene blue to saturation). The 
actual procedure would be (a). Place on cover slip small portion of 
selected sputum, (b). Spread it. (c). Dry thoroughly in the air. 
(d). Heat bypassing it deliberately but steadily through alcohol or small 
bunsen flame from 6 to 8 times, (e) . Stain with the f uchsin either by hold- 
ing the stain-covered coverslip over a flame for three minutes or placing 
it smear side down upon the surface of a Petri dish containing stain and 
heating to boiling point (steam and rising of small bubbles) for same 
period, (f). Pour off dye and add corallin decolorizing solution, repeat- 
ing and slowly draining it off five or six times, (g). Wash thoroughly. 
(h). Mount in balsam. The older direct decolorization method of 
Gabbett is coarser and involves the risk of decolorizing a certain 
number of the tubercle bacilli. The greatest patience is required in \ Caution 
these examinations and diagnosis should never be based upon a doubtful 
finding. Wherever there is one germ more can and must be found and 
terrible mistakes have resulted from hasty conclusions though far less 
deadly than the too common failure to find the germ when present. 



DISEASES OF THE NOSE, PHARYNX AND LARYNX. 



Diagnosis 

at sight. 



Laryngo- 
scope. 



This modern specialty has the advantage of permitting practically 
all diagnoses to be made at sight through the use of special appliances 
for that purpose. The larynx and post-nasal space are readily brought 
into view by the use of light reflected by a concave mirror upon the 
surface of a small plain mirror which receives the image of the structure 
to be investigated. The various forms of laryngoscopes are too familiar 
to need detailed description. 

Technique. — The essentials are (a). Strong, steady light and a good Essentials. 
reflector, (b). Properly heated laryngoscopy and rhinoscopic mirrors. 
(c). A steady hand and thorough knowledge of the anatomy of the parts. 

The long handled mirrors are held in the pen position and in the Technique 
case of the larynx are introduced without touching any structure until 
they press back the soft palate. The tongue is grasped in a dry napkin 
between the index finger and thumb of the unoccupied hand and held 
firmly forward. The index finger should rest against the lower teeth 
forming a support to steady the hand and prevent painful pressure 



n6 



MEDICAL DIAGNOSIS. 



Vocal 
cords. 



Naso- 
pharynx. 



Obstacles 
to examina- 
tion. 



Position of 
head. 



Turbinate 
hyper- 
trophy. 



L 



upon the median raphe If the mirror be steadily held at the upper 
angle an excellent view of the larynx is obtained, the upper portion of 
the image representing anterior, the lower, posterior structures. Deep 
breathing and voice production reveal the action of the .vocal cords. 
In this examination the attachment of the handle to the mirror is above. 
I In examining the naso-pharynx a smaller mirror is used and introduced 
well back to the posterior pharyngeal wall, the free edge of the mirror 
being upward. If the patient by deep breathing and passivity can 
maintain a relaxed soft palate the parts may be seen without difficulty, 
but oftentimes some one of the special forms of the palate retractors 
must be used to pull that structure firmly forward and slightly upward. 
Hesitancy, jumbling and tremor on the part of the examiner invariably 
cause retching, and occasionally hyperesthesia may be so marked as 
to necessitate the preliminary administration of a bromide or the use 
of a dilute solution of cocaine. The small mirror should invariably 
be surgically clean, warmed to prevent misting, and tested for excessive 
heat by laying its back against the skin of the hands. The patient's 
head should be slightly tilted backward to best show the larynx and 
held perpendicular or inclined forward in examining the naso-pharynx. 
The anterior nasal chamber is examined by direct light, the patient's 
head being tilted backward and the alae drawn outwards by means of 
a probe or one of the various nasal dilators, bringing into view the 
vestibule, septum, inferior meatus, inferior turbinate, middle meatus 
and middle turbinate. Obstructing secretion is sprayed or wiped 
away and congestion is readily reduced by cocaine or suprarenalin. 

DISEASES OF THE NOSE.— Acute Coryza (acute rhinitis).— A 
description of this universally known ailment is unnecessary. The suscep- 
tibility of an individual is markedly increased by the existence of a 
chronic catarrhal inflammation of the nasal passages, exhaustion, 
chronic diseases and lowered vitality from whatever cause. The 
mucous membrane in such cases shows primarily, congestion, swelling 
and diminished secretion, secondarily, the characteristic profuse muco- 
purulent discharge. 

Chronic Rhinitis (chronic catarrh). — Resulting from repeated 
acute attacks or due to general impairment of nutrition, presents much 
the same appearances as acute rhinitis. 

Hypertrophic Rhinitis. — By chronic catarrhal inflammation the 
vascular turbinate tissues become permanently distended and the 
epithelial layer thickened and infiltrated. This condition is frequently 
associated with exostoses or ecchondroses of the nasal septum and is 



DISEASES OF THE NOSE. 



II 7 



Chronic 
rhinitis. 



Mouth 
breathing. 



Deafness 
common. 



Headache. 



most marked at the anterior and posterior portions of the middle 
turbinate. The symptoms are chiefly those of chronic nasal obstruction 
and catarrh, which lead to mouth breathing and frequent acute or 
subacute aitacks. There is a troublesome recurrent obstruction 
especially marked in recumbency, such patients awaking in the morning 
with dry lips, coated tongue and oftentimes foul breath. The drainage 
of secretion is interfered with and may cause obstruction of the nasal 
duct; the senses of smell, taste and hearing may be markedly affected, 
and the Eustachian tube may be the seat of a catarrhal process. 
Headaches are common either as the result of infundibular occlusion 
or actual disease of the frontal sinus. 

Exostoses and Ecchondroses. — These formations are recognized 
at sight and their consistence determined by the use of the probe. 

Septal Deviations. — This condition, rarely absent in slight degree, is 
pathologic only when it produces pressure or absolute obstruction. 
Marked deviations lacking a history of traumatism are usually associated 
with a high arched palate and probably with previously existing adenoid 
growths of the naso-pharynx. They may be partial or general, angular 
or curved, are readily recognized upon examination and usually asso- 
ciated with chronic catarrh. 

Septal Haematoma. — Usually the result of an injury, it is recognized 
as a blood red tumor. 

Septal Abscess. — Is a frequent source of septal perforation and 
forms a fluctuating swelling. 

Atrophic Rhinitis (dry catarrh). — This is usually a sequence of 
chronic hypertrophic rhinitis and is characterized by foul breath and a 
dry glazed mucous membrane carrying scanty and foul secretions 
which dry into adherent and offensive scabs and scales. Not infre- 
quently, there is ulceration of underlying tissues and in long standing 
cases, actual structural atrophy, the turbinate bones being shrunken 
and the septum thin.* In delicate children the condition may coexist 
with a thin watery excessively fetid secretion (ozaena). 

Necrosing Ethmoiditis. — As a result of inflammation of the middle 
turbinate, necrosis of the inferior turbinate and other ethmoidal struc- 
tures may occur. Periostitis and necrosis are usually followed by the 
exfoliation of a limited amount of bone. The symptoms are those of a 
suppurative inflammation specially involving the middle turbinate. 



Foul 
breath. 



Pressure deviation of the septum is common and nasal polypi frequently 



*The n; 

in SUCh ra- 



il chambers look extraordinarily 



il characteristically rooim 



^ 



n8 



MEDICAL DIAGNOSIS. 



Period- 
icity. 



Widely 
varying 
causes. 



result and may remain as evidence of past disease. The probe intro- 
duced at the site of the suppuration usually detects the necrotic bone. 

Hay Fever (periodic vasomotor coryza). — However obscure the 
causal factors, the disease offers no diagnostic difficulties. The symp- 
toms are merely those of an unusually obstinate or persistently re- 
current acute coryza with a profuse watery rather than muco-purulent 
discharge, coming on periodically often at a stated day or week in each 
year and not infrequently associated, alternating with, or substituted 
by, attacks of pure bronchial asthma. The disease is most frequent 
in the later spring months (rose cold) and in August and September 
(hay fever) and in some instances occurs irregularly or following exactly 
such influences as are described under the exciting causes of asthma. 
In certain cases a violent harassing and markedly paroxysmal cough 
may be present. Slight fever may occur at intervals and the usual 
duration is from four to six weeks. 

Nasal Polypi. — These may be either mucous or fibrous, the former 
being soft and gelatinous, the latter hard. They are most common 
in the posterior chamber, may cause necrosis, invade the adjacent 
cavities, deform the nose and in the case of fibrous growths may become 
sarcomatous. 

Sarcoma and Carcinoma. — The sarcomata are usually sessile, light 
red in color and associated with ulceration and offensive discharge. 
Carcinoma is usually epitheliomatous or encephaloid in type and is 
excessively rare as a primary disease. 

Nasal Syphilis. — Primary lesions are almost unknown, secondary 
lesions coincide with the appearance of the exanthemata upon other 
parts, but tertiary lesions appear as nodular swellings on any part of the 
nose. Behaving here as elsewhere, they undergo absorption or necrosis, 
attended by a foul breath and a rapidly destructive necrosis of all 
tissues. No more terrible picture is presented than that of rapidly 
progressive syphilitic necrosis involving the nasal structures. 

Epistaxis. — Nasal hemorrhage occurs chiefly as a result of excessive 
physical and mental exertion, injuries, operations, erosions, ulcerations, 
tumors affecting the nasal mucous membrane, venous obstruction as in 
tumors of the throat and mediastinum and in mitral and tricuspid 
disease or high arterial pressure associated with left ventricular hyper- 
trophy or arterio sclerosis. Nasal congestion alone or as a part of a 
cerebral congestion gives rise to single or repeated hemorrhages and it 
occurs as a prodromal symptom of acute infectious diseases, especially 
typhoid, and is a complication of profound dyscrasias such as leukaemia, 



DISEASES OF THE PHARYNX. 



II 9 



haemophilia, scurvy and purpura, in which it may be fatal. Rarely 
it is a source of vicarious menstruation or hemorrhoidal bleeding, and 
it should be remembered that repeated hemorrhages often disregarded 
or overlooked in case-taking may be the source of a profound secondary 
anaemia. 

Foreign Bodies in the Nose. — In a child or insane person a mucoid 
discharge becoming purulent or perhaps fetid and bloody should suggest 
a foreign body in the nose, and demands a rhinoscopic examination. 

DISEASES OF THE PHARYNX.— Acute, chronic and atrophic 
pharyngitis present essentially the same symptoms as do similar lesions 
of the nasal mucosa. In the acute form the throat is sore, stiff and dry. 
There is dysphagia, hoarseness and in severe cases swelling of the 
cervical glands, the patient is continually trying to clear the throat 
and the secretion tends to become viscid and tenacious. Chronic 
pharyngitis presents much the same symptoms during its period of 
exacerbation and frequently shows a special involvement of the follicles, 
giving the throat a granular appearance, sometimes described as a 
separate disease, "follicular pharyngitis." The atrophic form shows 
a thin glistening mucous membrane, and the throat is dry and stiff and 
may be dotted with islands of dried secretion. The naso-pharynx 
may be chiefly involved leading to a dry burning sensation and most 
troublesome and irritating efforts to dislodge secretion (hawking). 
In acute conditions the secondary increase of secretion may be profuse. 
The atrophic form is especially disagreeable in this region and a hyper- 
trophic form may involve the lateral walls of the pharynx. 

Post-nasal Adenoids. — These lymphoid structures greatly affect 
the health, physical and mental development and future life of children. 
They represent hypertrophied lymphoid tissue and form vascular 
growths either broad based or sessile, sometimes moderately firm and 
fibrous. They are astonishingly frequent and may affect whole families. 
Excessively cold, or damp and changeable climates seem to increase 
their frequency and though the condition may be congenital it is seldom 
noticeable until the age of two years. The symptoms are varied and 
interesting. In the typical and pronounced cases the child is a mouth 
breather with the physiognomy shown in our illustration, p. 1 20, ami in such 
cases the growth is usually large. Smaller bodies may nevertheless 
produce marked irritability, restlessness and a complete change in the 
disposition and mental activity of the child. In all cases there is increased 
liability to acute coryza, croup, tonsillitis, laryngitis and bronchitis 
and added danger from attacks of measles, scarlet fever, whooping 



A source of 
ansemia. 



Impor- 
tance. 



Frequency , 
Climate. 

Symptoms, 

Mouth 
breathers. 



Mental 
effect. 



Invite 
disease. 



^ 



120 



MEDICAL DIAGNOSIS. 



Sequels. 



Reflex 
cause of 
disease. 



Usual site. 






cough and diphtheria. If unrelieved they may undergo atrophy as 
adult life approaches, usually leaving behind chronic naso-pharyngeal 
catarrh, high arched palate and a deformed chest. Mouth breathing, 
nasal voice and snoring and the evident increase of obstruction in the 
dorsal recumbent position should call attention to these cases. Im- 
paired hearing is extremely common and is due to involvement of the 
Eustachian tube. It is moreover one of the reflex causes of asthma, 




Fig. 46. — Facies of adenoid disease. (Courtesy of Dr. J. E. Schadle.) 

enuresis, night terrors, teeth grinding, gastro-intestinal disturbances, 
croup and possibly epilepsy and chorea* 

Syphilitic Pharyngitis. — A secondary erythema is diffuse or takes 
the form of a vertical red band on the anterior pillars, which ends abruptly 
at the uvula. An accompanying laryngitis is usually present. Mucous 
patches if present tend to symmetry but tertiary lesions are frequently 
unilateral. 

Retro-pharyngeal Abscess. — Such abscesses are unilateral and 
most often in the oro-pharynx, but may be opposite either the nasal or 

* The illustration shows a marked case presenting all of the typical symp- 
toms enumerated above, but after operation taking on a normal develop- 
ment and facial expression. 



DISEASES OF THE LARYNX. 



Causes. 

Symptoms 



Age. 

Related 

ailments. 



Exudate. 



laryngeal portion and are often to be seen only with the mirror. Injury 
and caries of the vertebrae are the usual causes though they may com- 
plicate tonsillar abscess, syphilis and tuberculosis. According to their 
location they cause obstructed nasal breathing, spasmodic dyspnoea, 
deafness, or tinnitus aurium, combined with symptoms of severe 
pharyngitis and the local and general symptoms of abscess. 

Paralysis and Tumors. — Paralysis of the pharynx need not be 
separately considered, the tumors of this region may take any form 
and belong to surgery. 

DISEASES OF THE TONSILS.— Acute Tonsillitis.— This com- 
mon disease of young people is rare in infants and the elderly. Its rela- 
tion to acute rheumatism, chorea, endocarditis and erythema nodosum is 
extremely suggestive. It prevails chiefly in the spring in this country 
and affects both sexes equally. 

Symptoms. — A chill or chilliness, muscular and bone pain are fol- 
lowed by rapidly rising fever, with sore throat and dysphagia; the tem- 
perature reaches 103-105 F., and the voice may be thick and nasal. 
The tonsils are swollen and dotted with a readily detachable exudate, 
which may become confluent, but tends to be limited to the tonsil. 
The disease lasts but a few days and is usually uncomplicated. In 
certain instances the diphtheric membrane may be so closely simulated 
as to demand cultural tests. 

Suppurative Tonsillitis (quinsy). — This differs from the- preced- 
ing form chiefly in the predominating involvement of one tonsil, more 
violent onset, higher fever and pulse rate and greater prostration. 
The local symptoms are those of pain, dysphagia and marked swelling 
of both the tonsil and the peritonsillar tissues. The cervical glands 
are enlarged, salivary secretion is increased and within two or three 
days fluctuation is evident and through rupture or by the use of the 
knife the disease passes. Both tonsils may be involved, the pus 
may burrow with unexpected rapidity, and edema of the glottis 
may occur. Quinsy should not be allowed to go on to spontaneous 
rupture. 

Chronic Tonsillitis. — Chronic hypertrophy often associated with 
dense adhesions, like naso-pharyngeai adenoids is closely associated 
to so-called lymphatism and the significance and effect of the two 
Lesions is essentially the same (see adenoids). 

DISEASES OF THE LARYNX. Simple, acute and subacute 
laryngitis are too well known to need extended description, their chief 
characteristics being varying degrees of hoarseness, painful and distress- 



Severe 

ailment. 



Dangers. 



(. ommon 

know n. 



Jt 



122 



MEDICAL DIAGNOSIS. 



ing cough, general congestion of the mucous membrane and vocal cords* 
and scant viscid secretion. 

Chronic laryngitis is a common complication of other diseases of 
the respiratory tract and a very frequent form of fatigue neurosis such 
as is experienced by singers, auctioneers, hucksters, army officers and 
others. In its milder forms it is associated with the excessive smoking 
of tobacco, overuse of alcoholics, and the rheumatic or gouty diathesis. 
It is particularly frequent in ail poorly nourished persons, especially 
such as live or work in dusty, steamy or vitiated atmospheres. Chronic 
or recurrent hoarseness of varying degree, scanty tenacious secretion, 
local irritation, laryngeal congestion and more or less cough are the 
chief symptoms. The vocal cords are sometimes unaffected and even 
whiter than normal, though occasionally their movement is restricted 
by swelling of adjacent structures. The cough may be paroxysmal or 
violent and projectile, the dried secretion acting like a foreign body. 
A form precisely similar to atrophic rhinitis and pharyngitis may occur. 

Edema of the Glottis. — Cases of sudden onset and rapidly fatal 
termination may occur but usually it is preceded by progressive inspira- 
tory dyspnoea with hoarseness or aphonia. The laryngoscope or even 
the finger at once reveals it and no condition more urgently demands 
prompt, often immediate, and radical treatment. It should be remem- 
bered that this condition may complicate actual traumatism, especially 
burns, or the inhalation of poisonous and irritating gases, the ingestion 
of corrosive poisons, diphtheria, erysipelas, quinsy, scarlet fever, typhus, 
Bright's disease, syphilis, tuberculosis and diabetes mellitus. It is very 
rare in association with primary acute laryngitis. 

Croup. — This well nigh universal ailment of children occurs between 
the ages of six months and three years, rarely later, and is undoubtedly 
a purely reflex condition, rickets, the irritation of teething, large tonsils 
and adenoid growths being the chief factors. The symptoms are those 
of spasmodic inspiratory dyspnoea. It is preceded by a characteristic 
hoarse, brazen, hollow cough, accompanied by marked hoarseness 
and during the spasm the child is cyanotic and asphyxiation may seem 
imminent. The peculiar crowing sound attending the forced indraft 
of air through the glottic chink is characteristic of the disease and familiar 
to both physician and layman. In many cases the attacks last only 
for a short time, usually coming on about midnight, in others they 
may recur on several successive nights and the child is hoarse and has 
a croupy cough. Convulsions rarely occur and death during the attacks 
is almost unknown. Laryngismus stridulus is a terma pplied to an 



A compli- 
cation se- 
quel or 
neurosis. 



Etiology 



Symptoms. 
Cords. 



Cough. 



Atrophic 
form. 



Prompt 
relief de- 
manded. 



Reflex 
dyspnoea. 



Laryngis- 
mus stridu- 
lus. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 



123 



adductor laryngeal spasm which may be either nocturnal or diurnal 
and lacks the hoarseness and cough of croup. It corresponds to "passion 
fits" "child crowing," "holding the breath" of the laity and convulsions, 
carpo-pedal or general, may occur. 

True Croup (membranous croup). — In rare instances especially 
in measles and pertussis this terrible disease is unassociated with diph- 
theria, but ordinarily any persistent laryngeal stenosis suggests a diph- 
theritic membrane and demands prompt intubation and large doses of 
diphtheria antitoxin. 

Syphilitic Laryngitis. — This is ordinarily a tertiary lesion and may 
occur two or three decides after the primary infection. The secondary 
stage may however give rise to hyperemia, symmetrical ulceration 
and condylomata which may resolve or ulcerate. The gumma may 
cause deep ulceration or necrosis with resulting stenosis from cicatricial 
contraction. The therapeutic test is often necessary. Congenital 
laryngeal syphilis usually appears in infancy, more rarely at the age of 
puberty (hereditaria tarda). 

Tuberculous Laryngitis. — Primary tuberculosis in this region is 
extremely rare and usually though not always the lesion indicates an 
advanced pulmonary lesion.* The symptoms are those of a persistent 
chronic laryngitis, hoarseness or aphonia being a marked and early 
symptom and swallowing painful if there is epiglottic or pharyngeal 
ulceration. The laryngeal mucous membrane is at first pale and later 
an ashy gray, the arytenoids show a pyrijorm swelling and the epi- 
glottis is turban shaped. The ulcers themselves are shallow and broad 
with gray bases and irregular outlines, and the vocal cords usually 
appear "moth eaten" from ulceration. The tubercle bacillus can usu- 
ally be demonstrated easily and makes the diagnosis positive. 

Tumors of the Larynx. — The general symptoms of laryngeal 
tumors are dysphonia and aphonia, intermittent or persistent dyspncea, 
cough, and sometimes laryngeal spasm. Certain growths above the 
cords are subjectively symptomless and some sessile growths produce 
strikingly intermittent and irregular symptoms with violent paroxysmal 
cough and are often difficult to see with the laryngoscope. 

f DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 
ACUTE AND CHRONIC BRONCHITIS.— Etiology.— The eti- 

ologic factors are essentially the same in all forms of simple bronchitis. 

* Nearly all of the supposedly primary cases prove to be secondary to 
advanced but latent or partially arrested pulmonary lesions. They will be- 
come still rarer as the X-Ray is more generally usea in diagnosis. 



Usually 
diphtheria. 



Usually 
tertiary. 



Therapeu- 
tic test. 



Seldom 
primary. 



Hoarse- 
ness, 

cough and 
aphonia. 

Ashy gray 
color. 

l'vriform 
swelling 
and epiglot- 
tic turban. 
Moth eaten 
cords. 



w 



124 



MEDICAL DIAGNOSIS. 



Climate. 



Previous 
health. 



Antecedent 
diseases. 



Sex. 

Age. 

Occupa- 
tion. 



Coryza. 



" Harden- 
ing" in- 
fants. 



Fever. 
Cough. 
Sputum. 



Rales 

chiefly. 



Brief 

duration. 



A changeable, damp climate, whether temperate or tropic, is a potent 
factor and general low vitality invites it. Chronic gout, alcoholism, 
Bright's disease, incompensated mitral lesions and malaria predispose to 
, it and it invariably accompanies tuberculosis, emphysema and asthma. 
In acute disease such as measles, typhoid, smallpox, influenza and 
whooping cough it is a common or invariable complication. Males are 
chiefly affected by reason of their greater exposure to climatic influences 
and the diseases of etiologic relationship, and it is particularly prevalent 
' at the extremes of life. Steel grinders, stone cutters, bakers, millers, 
stokers, felt workers, and employees in flax and cotton mills show a 
special tendency to this disease but so far as acute bronchitis is con- 
cerned the common "coryza" is ordinarily the exciting factor, the disease 
extending apparently by continuity of structure from the upper to the 
lower air passages. The mistaken and foolhardy process of "hard- 
ening" young infants by reckless exposure to harsh weather is a potent 
factor in the production of the disease in infants and young children, 
and helps greatly to swell infant mortality. 

Morbid Anatomy. — At first, in acute bronchitis, the mucous mem- 
branes are inflamed, dry and irritable, later there is muco-purulent secre- 
tion, the membranes are swollen, may be edematous, and should the 
bronchioles become affected a disseminated broncho-pneumonia 
(capillary bronchitis) results. In chronic bronchitis the long continued 
inflammatory changes lead to permanent thickening or atrophy, granu- 
lation or even ulceration and it is one of the causes of a fusiform or 
saccular dilatation known as bronchiectasis. 

The symptoms of acute bronchitis are fever, usually moderate, 
(99.5°-io3° F.) substernal pain, soreness or oppression, hoarseness, 
general malaise, cough, at first dry, ringing, harsh and somewhat painful, 
later moist and hollow. The sputum, at first mucoid and scant soon 
becomes muco-purulent and sometimes profuse, and if the cough is 
violent may show blood streaks. 

Physical Signs. — The only important physical signs are the 
sibilant and sonorous rales of the first stage followed by the mucous, 
bubbling or even gurgling rales, of the stage of exudation. Slight 
dyspnoea and cyanosis may be evident, and palpation may reveal 
rhonchal fremitus. Marked cyanosis suggests disseminated broncho- 
pneumonia, a preexistent emphysema, or a complicating cardio-vas- 
cular lesion. 

Prognosis. — It lasts from a few days to several weeks and one may 
ordinarily anticipate a prompt and complete recovery and freedom from 



DISEASES ASSOCIATED WITH CHRONIC BRONCHITIS. 



125 



Fundamen- 
tal points. 



relapse save in those persons exhausted by antecedent disease or badly 
nourished. 

Symptoms of Chronic Bronchitis. — This is essentially a secondary 
disease; the hereditary element may be marked; it is an invariable 
accompaniment of asthma, in compensated mitral disease or emphy- 
sema and many persistent cases are associated with chronic diseases 
of the kidneys. The diagnoses of "chronic bronchitis" and "winter 
cough" have of late years diminished, as exact methods have proven 
many, especially in the young, to be cases of pulmonary tuberculosis. 
Putrid bronchitis is chronic and characterized by foul smelling sputum, 
but hardly deserves a separate place because of its almost invariable 
association with bronchiectasis, gangrene, and a ruptured abscess, or 
empyema. 

Physical Signs. — Unless, as is commonly the case, one finds well 
marked symptoms of emphysema, the physical signs of this ailment 
are limited to sibilant, sonorous, mucous or bubbling rales with more or 
less profuse expectoration. 

In fibrinous bronchitis fibrinous casts are formed and expelled; 
these are often extensive and sometimes produce bronchial blocking and 
atelectasis of lung areas. Dyspnoea and cough are more urgent than in 
ordinary bronchitis and the attacks may be single, recurrent, acute or 
chronic. It is a clinical curiosity. 



DISEASES ASSOCIATED WITH CHRONIC BRONCHITIS. 



Putrid 
bronchitis. 



Chiefly aus- 
cultatory. 



Fibrinous 
casts. 

Urgent 
symptoms. 



Varieties. 



EMPHYSEMA. — This may be acute or chronic, general or local, 
interstitial or vesicular, and a vesicular emphysema may be either 
atrophic or hypertrophic. A localized emphysema may be temporary 
or permanent and is usually vicarious, representing the effect of over- Vicarious 
act : on associated with temporary or permanent loss of function in 
other portions of the lungs. The best examples are seen in pulmonary 
tuberculosis. Interstitial Emphysema. This condition is caused by 
the rupture of a superficial or deep air vesicle which, during violent 
cough or straining, permits the escape of the air into the areolar tissues 
and produces either (a) interlobular or (b) subcutaneous emphysema, 
or even (c) pneumothorax according to the site and degree of its exten- 
sion. Subcutaneous emphysema is especially common in connection 
with traumatism involving the lung structure ami is at once detected 
by the exquisite crackling produced by the pressure o\ the fingers upon 
the distended skin. The atrophic or small hinged emphysema hardly 
merits a special description and is essentially a senile condition. 



Ruptured 
intervesic- 
ular septa. 



Crack- 



lini 



^ 



126 



MEDICAL DIAGNOSIS. 



Bronchitis, 
dyspnoea 
and cyano- 
sis. 



Barrel 

chest. 



Chest 
movement. 



Apex beat 
obscured. 



The common form of emphysema is the vesicular hypertrophic. In 
this variety the air cells are overdistended, their walls weakened and 
prone to rupture and, as a result, the lung is increased in size, its 
alveoli tend to become fused in certain areas and its circulation and 
expansile power are greatly affected. 

Symptoms. — The symptoms are primarily those of a chronic bron- 
chitis plus slight or intense cyanosis, dyspnoea, persistent or developed 
by exertion, and certain well denned and easily 
recognized physical signs. A considerable de- 
gree of emphysema may exist without dyspnoea 
or persistent signs of bronchitis, yet it repre- 
sents the most profound cases of cyanosis seen 
in adult walking patients. Cough. Cough 
may be variable in degree as in persistence and 
may be dry, moderately productive, or accom- 
panied by profuse expectoration. In severe 
cases it is somewhat characteristic, each in- 
dividual paroxysm being greatly prolonged 
diminuendo. 

Inspection. — The shape of the chest represents that of forced held 
inspiration (barrel chest). The anteroposterior diameter is increased, 
the epigastric angle wide, true expansion is largely replaced by a vertical 
lifting movement, and constant overuse makes prominent the accessory 




Fig. 47. — Emphysema- 
Attitude frequently as- 
sumed, concealing barrel 
form of chest. 




Fig. 48.— Emphysema. Same chest, patient in 
dorsal recumbent posture. 

muscles of respiration, particularly the sternomastoids. The ribs are 
rigid, the interspaces broadened and the expiratory descent of the 
thorax is prolonged. The apex beat of the heart is ordinarily invisible, 
the neck appears short and a compensatory curve of the spinal column 
may cause the chest to appear flattened and the patient round-shouldered. 
If such a one be placed upon the back on a table, the chest will at once 






FOREIGN BODIES IN THE BRONCHI. 



127 



assume its typical emphysematous outline. Epigastric pulsation is 
common and Litten's sign shows an abnormally slight range of dia- 
phragmatic excursion confirmed by the fluoroscope which also shows 
abnormally bright lungs. 

Palpation. — Palpation confirms inspection and reveals enfeebled 
fremitus and apex beat and usually a liver displaced downward. 

Percussion. — Percussion develops hyperresonance, low position of 
the lung border, impaired movement of the lung bases and apices, 
displacement of the liver and diminution or entire absence of the 
superficial cardiac area.* 

Auscultation. — The breath sounds are enfeebled and expiration is 
prolonged though usually low pitched. Bronchial rales are ordinarily 
present at the base, the heart sounds are muffled, especially in the 
mitral area, but the pulmonary second sound though enfeebled may 
show relative accentuation. In old and severe cases tricuspid regur- 
gitation may be present. 

Secondary Symptoms. — The effect of long standing severe emphy- 
sema is to over-burden the pulmonary circulation and right heart, hence 
if incompensation follows one may expect to find the symptoms of a 
cardiac lesion. As a matter of fact such severe terminal symptoms are 
rarely encountered though minor degrees of secondary congestion 
affecting the organs tributary to the great veins are extremely frequent. 

FOREIGN BODIES IN THE BRONCHI. - Coins, whistles, nails, 
pins, tacks, buttons, jewelry, bullets, pebbles, false teeth, tooth crowns, 
bones, fruit stones, peas, beans and the like may be drawn into the glottis 
and usually fall promptly in the larger right bronchus. Violent cough and 
air hunger or true stenotic dyspnoea and cyanosis usually follow and 
are associated with widely varying degrees of pain. If the object is 
not expelled death may result in a few minutes but more often the 
attack subsides and secondary inflammation, often suppurative, ensues 
and results in localized septic broncho-pneumonia, abscess, or even 
gangrene. In some instances chronic pneumonia with or without 
bronchiectasis results and lasts for months or years ending rarely in the 
extrusion of the foreign body. 

Diagnosis. — This depends upon the anamnesis, violent paroxysmal 
cough, the Roentgen ray findings and the physical signs of localized in- 
flammation often associated with airless areas representing atelectasis. 

BRONCHIECTASIS.— Rarely congenital, it ordinarily follows 

*In certain cases marked dulness may be present at an apex arid in 
others the general percussion note is not dearly hyperresonant 



Useful ma- 
noeuvre. 
Litten's 
sign, 



Low 
borders. 



Enfeebled 
sounds. 



Cardiac 
strain. 



Immediate 

symptoms. 



Sequle.x. 



Usually 

simple. 



J 



128 



MEDICAL DIAGNOSIS. 



Typical 

sputum. 



Curious 
factors. 



chronic inflammation of the bronchial wall alone or with chronic ob- 
struction and accumulation of secretion, as in pulmonary tuberculosis, 
chronic pleurisy with adhesions and retraction or fibroid disease of the 
lung. Though rarely associated with acute diseases, it has been 
reported in influenza and broncho-pneumonia. 

Physical Signs. — Often absent, they, when present, are merely those 
of lung cavity, usually lacking the distinguishing qualities of a vomicus 
occupying infiltrated tissue. Hence the diagnosis of bronchiectasis usu- 
ally rests upon the presence of causative factors, the peculiar paroxysm 
of cough and the characteristic sputum. 

Cough. — Once or twice daily, usually in the morning on arising, a 
violent paroxysm of coughing occurs attended by extraordinarily pro- 
fuse expectoration. This is offensive in odor, gray or grayish brown and 
purulent and upon being placed in a glass it will after a time separate 
into three layers. The lowest is thick and granular; there is a thin 
mucoid intermediate layer, and the surface layer is brown and frothy 
(high air content). Changes of attitude may greatly influence the 
onset of cough, and to empty the bronchiectatic cavity some patients 
assume an attitude that brings the head below the body. 

Prognosis. — The condition once established is permanent, progres- 
sive, and rarely relieved save by operative measures. 

SPASMODIC ASTHMA.— Definition.— A respiratory neurosis of 
ill-defined causation characterized by more or less severe paroxysms of 
expiratory dyspnoea, tending to chronicity and associated with bronchitis 
and emphysema. 

Etiology. — It is often closely associated with, or a manifestation of, 
hay fever, but many cases show bronchitis, polypi, adenoids and super- 
sensitive or hypertrophied turbinate bodies, intestinal auto-intoxication 
or irritation, malnutrition, hysteria, neurasthenia or epilepsy. 

Exciting Causes. — Careful inquiry should be made concerning the 
exciting causes and the number and variety of the attacks. Such 
patients become close observers and can often describe with exactness 
the clinical phenomena and apparent exciting cause. Amongst these 
are odors of all sorts; those of drugs, of certain flowers, of hay, of horses 
or dogs or cats, fish, game or coffee; irritants such as dust or fog; 
heat or cold, whether local or general. Old feather beds and pillows 
have in more than one instance proved causative factors and emotions 
such as pleasure, pain, joy and sorrow, sexual stimuli, grief and worry 
are alike potent. In certain instances heavy meals at night and certain 
articles of food or drink may cause a seizure and in some cases it is 



^ 



SPASMODIC ASTHMA. 



129 



distinctly related to the menstrual epochs. Chronic poisoning, such 
as that from gout or lead, intestinal worms, and various occupations 
exposing their followers to dust or alternations of heat or cold may 
excite attacks. 

A Word of Warning. — The utmost care should be observed to 
avoid the common and disastrous error of confounding the so-called 
"renal," "aneurismal" and "cardiac" asthmas with those of the ordi- 
nary spasmodic type. The paroxysms of "renal asthma" are absolutely 
like those of true asthma and the cause can only be determined by a 
careful examination and quantitative analysis of the 24 hours urine, 
for the attacks are usually coincident with low urea excretion. The 
pseudo-asthmatic paroxysms produced by aneurism of the aortic arch 
may deceive the elect, but are fortunately rare. Cardiac Asthma. 
Ordinary cardiac dyspnoea is either persistent or distinctly dependent 
upon exertion and is inspiratory in type or a mere air hunger. Never- 
theless true asthmatic attacks occur as the result of weakened hearts 
and in established asthma the heart strength is an important factor 
in the treatment and prognosis.* Males are chiefly affected, the 
ratio being as two to one, and 80% of all cases appear in persons 
under 40 and \ in those under 10. It is distinctly an hereditary alter- 
native. 

Theories as to Causation. — Five may be mentioned. 1st. Bronch- 
ial spasm, i.e. spasmodic contraction of the muscles controlling bronch- 
ial caliber. 2nd. Hyperemia and swelling of the mucosa. 3rd. Spasm 
of the diaphragm. 4th. Spasmodic contraction of other inspiratory mus- 
cles. 5th. Exudative bronchiolitis. Bronchial spasm (1), congestion 
and the attending exudation (2 and 5) are undoubtedly the most promi- 
nent factors, while it is not impossible that all five may be operative in 
varying degrees. 

Time of Attack. — Like croup, angina and nocturnal epilepsy, at- 
tacks of asthma occur usually at midnight or in the early morning 
hours. 

Aurae. — Like epilepsy attacks of asthma may be preceded by pre- 
monitory symptoms recognized by the patient. Amongst these are 
mental depression or exaltation, flatulence, yawning, sneezing, itching, 
headache and polyuria. Ordinarily, however, the attacks occur with- 
out any such warning. 

*In a case recently observed typical asthma of long standing was 
promptly and completely relieved by treatment directed wholly to a dilated 
heart and this experience is a common one. 

9 



Renal and 

cardiac 

asthmas. 



Exertion 
dyspnoea. 



No one 
causative. 



J 



Ws 



130 



MEDICAL DIAGNOSIS. 



Onset. 



Dyspnoea. 



Facies. 



Attitude. 



Spirals and 
crystals. 



Heart. 



Recurrent. 



Chronic. 



Shortens 
life. 



Symptoms. — The onset may be gradual, but is usually sudden. 
There is a sense of constriction of the throat or chest and pronounced 
dyspnoea with difficult, stridulous and prolonged expiration. In spite 
of the frenzied gasping the rate is usually below normal. A short, dry, 
feeble cough increases the patient's discomfort, and an acute emphy- 
sema enlarges the girth of the lower chest so that the female patient, 
if attacked when dressed, is obliged to loosen the clothing. The eyes 
are bloodshot and staring, the voice gasping and weak, the face 
pallid, cyanotic, drawn and agonized. The mind is absolutely clear 
and the patient appreciates his suffering and is usually apprehensive 
and fearful. If in bed, the knees are drawn up, the shoulders advanced, 
the back rounded, and the head is on the hands, or, sometimes one will 
be found leaning over a chair or bed-post or thrown back with raised 
arms grasping some support that will give added purchase to the 
accessory muscles of inspiration. In many cases patients rush to an 
open window, regardless of extremes of temperature. 

Examination of the Chest. — Inspection shows an increased basal 
girth, dyspnoea, defective movement, inactive diaphragm, costal breath- 
ing and rigid abdominal muscles with which the patient is seeking to 
reinforce the respiratory muscles. Palpation. The rales are easily felt 
and vocal resonance and fremitus are enfeebled. Percussion and Aus- 
cultation. The signs are those described under emphysema with bronch- 
itis stridor superadded. 

Cough. — This is ordinarily feeble and unproductive until the end 
of an attack, when there may or may not be a considerable amount of 
sputum. In cases of pure asthma uncomplicated by bronchitis one 
may find the pearly globules of the size of a hemp seed which contain 
Curschman's spirals and Charcot Ley den crystals (see page 112). 
Pulse. The pulse may be markedly weak and accelerated. During 
any severe attack the right chambers of the heart are dilated yet 
death during an attack is most unusual. Duration of the Paroxysm. 
Attacks usually end gradually, less often abruptly after two or three 
hours, but may be shorter or much longer, usually recur with in- 
creasing severity on successive days and are followed by a period of 
immunity. 

Prognosis. — The attacks are recurrent and chronic and asthmatics 
may endure them for a reasonably long life time, but on the average 
there is, nevertheless, marked shortening of life expectancy as is proven 
by life insurance statistics. Asthma occurring in childhood usually de- 
pends upon a removable cause and is often curable. Those cases occur- 



PLEURISY. 



I.3I 



ring between the ages of 10 and 20 are sometimes cured, those of the 
intermediate period are rarely cured, and those in patients above 60 
years of age, it has been said, are never cured. The author's experience 
would indicate that at no age is the last statement absolutely true. 
Careful and thorough study of causative factors may bring relief in 
some apparently hopeless cases but the cure of secondary conditions 
of long standing is never possible in the adult. 

PLEURISY (pleuritis). — Definition. — An inflammation of the 
pleura, acute or chronic, with or without an exudate which may be 
serous, bloody or purulent. 

Applied Anatomy. — Each pleura completely invests its lung, dips 
between the lobes and is reflected upon the chest wall so as to form a 
potential closed cavity, though normally parietal and visceral layers 
are in close apposition and move freely over one another, lubricated 
by the normal lymph. The pleural cavity resembles a great lymph 
space structurally continuous with the diaphragm, pericardium, cervical 
fascia, chest wall and lung. The pleural folds or sinuses and Traube's 
space are discussed on page 82. When inflamed, the pleural surface 
becomes dry, and the attrition gives rise to pain, cough, and the character- 
istic physical sign of dry pleurisy, viz.: — audible, often palpable, friction 
sound. A slight attack may (a) terminate promptly without perma- 
nent damage to the pleura, (b) the fibrinous exudate may become 
organized and form pleural adhesions of variable extent and density, 
or (c) a serous exudate may result, relieving the pain by separating the 
pleural layers and in its turn be reabsorbed or become converted into 
pus (empyema). The character of the exudate varies greatly with the 
cause of the pleurisy and the nature of the germs present. Bloody fluid 
most often indicates malignant growths of the lung and pleura. Puru- 
lent exudate is usually the result of neglected effusion, but is often 
primary, particularly in the cases associated with the lobar pneumonia 
of children. If one bears in mind the important structures contained 
in the mediastinum, one can readily appreciate the importance of the 
pressure symptoms and the degree of displacement of the heart as a 
result of large unilateral effusions. The lung of the affected side is 
compressed from below upward and towards its root pari passu with 
the increase of exudate and may remain permanently crippled and 
bound down by adhesions after resorption of the exudate. Pleurisy is 
almost invariably present in lobar pneumonia, but in adults it is seldom 
associated with a marked degree of effusion. It is generally believed 
that the greater number of so-called simple pleurisies represent a local 



Age 

important. 



Anatomy 
explains 
much. 



Termina- 
tions. 



Varieties. 



Exudates 



Pressure 
signs. 



J 



132 



MEDICAL DIAGNOSIS. 



Tubercu- 
losis. 



Germs. 



Associated 
diseases. 



Referred 
pain. 



Character- 
istics. 



Decubitus. 



Excessive 
pain. 



ized tuberculosis and the statistics of foreign observers show a percent- 
age of tuberculous pleurisies ranging from 25-90%.* 

Etiology. — The pneumococcus, staphylococcus, streptococcus and 
tubercle bacillus may be found alone or in combination in cases of 
purulent pleurisy and to these may be added the influenza, typhoid 
and colon bacillus. Pleurisy may appear as a complication of various 
diseases. First in importance are tuberculosis, lobar pneumonia and 
pericarditis, but peritonitis, influenza, acute rheumatism and chronic 
nephritis are frequent. It may occur in the exanthemata, in typhoid 
fever and the acute infectious diseases generally, as well as in gout, 
chronic diseases of the liver and gall-bladder, and in cancer. Trau- 
matism of the chest with or without perforation may cause it. 

Symptoms of Acute Fibrinous Pleurisy. — (1). Fever, usually mod- 
erate in degree and lasting but a few days. (2). Pain, most com- 
monly felt in the axillary or inframammary region yet sometimes not 
localized at the seat of the process, but referred to the terminations of 
the intercostals or even to the sound side. It may be fixed, stabbing 
or shooting in character, and is increased by deep breathing and cough. 
The fact that abdominal pain may be pleuritic in origin should never 
be forgotten for many important surgical conditions may be simulated. 
(3). Cough; this is harsh, unproductive, painful and suppressed. (4). 
Friction; auscultation yields a shuffling creaking, squeaking, or even 
a crackling sound simulating at times true crepitation or even rhonchi, 
but persisting after cough, superficial in character and usually occurring 
early in the inspiratory phase of a respiration. Friction is often palpable 
as well as audible. 

Physical Signs. — Inspection reveals shallow catchy breathing, 
comparative immobility of the affected side, and painful cough. 
The patient's decubitus is variable, oftentimes he lies upon the affected 
side as if to limit its movement during the stage of congestion and 
give greater latitude to the expansion of the sound side after effusion. 

Diaphragmatic Pleurisy. — The pleurisy may not extend beyond 
the diaphragmatic surface, but usually other portions are involved. 
The physical signs may be absent or be those of acute pleurisy, with 
fever, rigid abdominal muscles, costal breathing and an extraordinary 
degree of pain on breathing, swallowing, talking and laughing and 
tenderness over the region of the 10th rib. It may be acute or chronic, 
dry or wet, serous or purulent and the excessive epigastric or inferior 

* These are based upon the injection of large amounts of exudate into 
susceptible animals. 



PLEURISY. 



*33 




Fig. 49- 
(Left) and Encapsulated 
Fluid (Right). Compression 
of the lung on left side as in 
pleural effusion. 



marginal thoracic pain attending diaphragmatic movement even of 
slight degree is the chief symptom. 

Pleurisy with Effusion. — The first effect of effusion is to separate 
the inflamed surfaces, relieve pain and diminish the area of friction 
sounds. The fluid gravitates to the most dependent portions, and if 
not encapsulated by adhesions is movable and slightly or markedly 
changes its level according to the position of the patient and the amount 
of effusion. Owing to the conformation of the- chest and the peculi- 
arities of internal pressure the upper line of 
pleural effusion often makes an S-like curve, 
reaching its maximum height in the mid- 
axillary line. If the fluid reaches the middle 
of the second rib this curve disappears. 

Physical Signs. — Inspection.— One notes 
immobility of the affected side, flush inter- 
spaces,* increased dyspncea, with cyanosis or 
Pneumothorax even m extreme cases lividity, and, a displace- 

iincapsulated J r 

ment of the heart to the opposite side which 
may carry the visible cardiac impulse to the 
axilla on the left side or to the right mid- 
clavicular line. Occasionally in moderate left-sided effusion no cardiac 
impulse is visible. 

Palpation. — Palpation confirms inspection. Palpatory percussion 
reveals marked resistance over the exudate. Percussion reveals a flat 
note, decidedly differing from that of consolidation and simulated only 
by pleural growths and dense pleural adhesions. Above the level of 
the fluid anteriorly, the note is often hyperresonant or tympanitic in 
quality (Skodaic resonance). Little difficulty is ordinarily encountered 
in delimiting the upper border of the effusion or in following its slow 
alterations of level with changes of posture. Posteriorly, duhicss due 
to a compressed lung may be encountered and well above the fluid level 
in established effusions the unaffected tissue may yield the hyper- 
resonance of vicarious emphysema. Movable duhicss in Traubc's 
semilunar space often reveals very small exudatess if light percussion 
is used. The note is not typically flat but passes sharply from slight 
dulness to pure stomach tympany as the patient changes from the erect 
to the recumbent posture. 

Auscultation. — Over the compressed lung posteriorly the breathing 



Relief 
afforded. 



Borders 

and 

mobility. 



Displaced 
heart. 



Resistance 

and 

flatness. 



Hyper- 
resonance. 



Light 

percussion. 



* The "bulging interspaces 
exudative pleurisy. 



are a clinical curiosit} 



;impK 



!34 



MEDICAL DIAGNOSIS. 



is tubular but below the level of the fluid the voice and breath sounds 
are markedly obscured, though seldom entirely lost. Over the elastic chests 
of children and even in adults conducted breath sounds may suggest 
true consolidation,* though usually of a distant quality. Pleuritic 
friction may be heard above the level of the fluid, particularly if this 
is receding and may persist for long periods either as friction or crepi- 
tation. 

Mensuration. — In large effusions the measurement of the affected 
side is increased. 

Fluoroscopy. — The diaphragm of the affected side is lowered and 
shows a greatly lessened respiratory excursion and the fluid is clearly 
indicated by the corresponding shadow. 

Rhythmic Lateral Displacement of the Heart. — In 1902, the au- 
thor reportedf observations based upon a number of cases of pleuritic effu- 
sion which indicated that this condition might be accurately diagnosticated 
by fluoroscopic methods, or even by auscultatory percussion and occa- 
sionally by inspection. He found that in the presence of a considerable 
unilateral effusion, the heart, in addition to its displacement, showed a 
distinct lateral movement of respiratory rhythm varying with the depth 
of respiration and the amount of effusion. In some cases, the super- 
ficial heart impulse could be seen to move from side to side; in nearly 
all, auscultatory percussion verified the observation, and in every case 
the fluoroscopic findings were positive. The phenomenon seems to 
depend chiefly upon the. piston-like action of the diaphragm in- 
itiated by the thrust of the abdominal muscles. In full inspira- 
tion pressure is relieved by the descent of the diaphragm and the 
expansion of the chest, and the readily movable heart tends to ap- 
proach the median line. In forced expiration, the rising fluid column J 
and the narrowing chest force the organ away from the median line, 
sometimes to the extent of two inches. The importance of the obser- 
vation depends upon the fact that it it does not occur under conditions 
such as subdiaphragmatic abscess or in other conditions likely to be 
confounded with pleurisy, either serous or purulent. The maximum 
range of movement occurs in medium sized effusions; in very small effusions 

* Recently the author removed over 1500 c.c. of serous fluid from an 
elderly patient in whom pure tubular breathing was marked throughout the 
area of flatness. 

fNew York Medical Journal, 1902. Transactions of the Association of 
American Physicians, 1905. 

+ In every case so far examined the upper border of the effusion was 
seen to rise in expiration. 



EMPYEMA. 



135 



there is practically no movement; in massive effusion both the chest and 
diaphragm are almost passive, yet in no such case so far observed has 
the author found an entire absence of upward thrust and lateral cardiac 
displacement. Hence he has not been able to confirm the statement 
made by certain writers to the effect that in massive pleurisies the 
diaphragm is completely immobile and may even bulge into the abdom- 
inal cavity. In every case so far observed the diaphragm on the affected 
side has shown movement of some degree and must if the abdominal 
muscles act strongly. Forced respiration is necessary and might demand 
the exhibition of morphia if pain were severe. In no instance so far 
observed has this been necessary. 

EMPYEMA. — Symptoms. — To the symptoms of serous effusion are 
added: — Intermittent (septic) temperature, sometimes a localized edema, 
and, in rare instances, actual bulging of the interspaces or the escape 
of pus from the pleural cavity through the intercostal space where it 
forms a tumor beneath the skin and may cause an intractable fistula 
through spontaneous rupture. Such perforations usually occur in 
the antero-lateral portion of the chest. The urine may show albumose 
(see p. 325); marked leucocytosis is the rule, the average count being 
about 18,000 and few falling below 12,000,* and the blood may 
show iodophilia (see p. 394). 

The Use of the Hypodermic Needle. — Aspiration may sometimes 
be performed with an ordinary hypodermic syringe, but one usually 
needs one of the larger syringes of the same type with a long needle 
of greater calibre. Such an examination, performed under proper 
antiseptic precautions, is absolutely without danger even though the 
needle enters the lung. The physician's fingers laid upon the ribs 
should mark the limits of the interspace and the needle should be 
thrust quickly and deeply between them without touching the rib. If 
fluid be present and the point entered be rendered anesthetic by the 
ethyl chloride spray the procedure is painless. The site of the puncture 
is ordinarily the 5th interspace in the axillary line, but it is often necessary 
to enter the chest at other points representing maximal dulness, and if 
care be taken to avoid the heart, spleen, liver and diaphragm the operator 
has a wide latitude. 

Pleuritic Adhesions. — A clinical diagnosis of slight adhesions 
is often impossible, but in general, the symptoms are as follows: — 

* In simple serous pleurisy a few eases may show moderate leucocytosis 
during the febrile period, but in 52 eases examined by R. C. Cabot, the 
average count was 8,820, and in only 9 did it exceed 12,000. 



Symptom 
constant. 



Wet pleu- 
risy plus 
sepsis. 



Blood 
findings. 



Danger 
almost nil. 



Painles 

usually 



136 



MEDICAL DIAGNOSIS. 



Lagging 

and 

retraction. 



An obscure 
disease. 



Usually n 
berculous. 



Inspection shows impaired movement of the affected side or retrac- 
tion if extensive adhesions are present and Litten's sign may show 
marked Jmpairment of the diaphragmatic excursion on the affected side. 

Palpation shows diminished vocal fremitus and lessened expansion. 

Percussion shows a change of note varying from slight dulness to 
absolute flatness according to the extent and density of the adhesion. 
Auscultation shows diminished breath sounds and voice conduction, 
and oftentimes in certain areas pleuritic rales. 

Fluoroscopy. — A distinct shadow indicates extensive adhesions and 
the diaphragmatic movement is markedly impaired. 

Interlobar Pleurisy. — This ordinarily takes the form and pre- 
sents the symptoms of an interlobar abscess situated between the 
upper and middle lobes near the root of the lung. It presents great 
difficulties to the diagnostician and is ordinarily mistaken for true 
pulmonary abscess on account of its peculiar location. The purulent 
accumulation may vary from an ounce or two to a pint or more. It 
ordinarily follows a general pleurisy. 

Chronic Pleurisies. — These may be dry or wet, serous or puru- 
lent, and for the most part present the same physical signs as are 
found in acute disease. Chronic pleurisies are usually tuberculous and 
the same may be said of chronic empyema, but they often represent 
neglected non-specific cases. Malignant disease of the pleura is at- 
tended by hemorrhagic effusion and chronic inflammation. 

Course and Termination of Pleurisy. — Simple plastic pleurisy 
runs its course in a few days, leaving behind, ordinarily, a few adhe- 
sions often discoverable only at post mortem. In cases with serous 
effusion aspiration is usually required, but spontaneous reabsorption is 
not uncommon. Empyema ordinarily demands surgical interference 
and leaves behind a variable area of thickened adherent pleura, and a 
more or less crippled lung. 

PNEUMOTHORAX.— Definition— An effusion of air into the 
pleural cavity. An exudate is almost invariably present, and the true 
descriptive terms are hydro pneumothorax and pyopneumothorax, the lat- 
ter being the common form. 

Etiology. — By far the greater number (90%) are associated with 
advanced tuberculosis of the lung and the formation of a fistulous 
communication, though in neglected empyema a fistulous opening 
may originate in the pleura. Amongst other causes may be mentioned 
penetrating wounds of the chest wall, traumatic rupture of the lung, 
rupture of emphysematous vesicles, pulmonary abscess, gangrene, in- 



Usually tu- 
berculous. 



PNEUMOTHORAX. 



137 



farct, cancer and even hydatids. Nearly all of the cases occur in males 
and the disease is invariably unilateral; sudden and complete bilateral 
pneumothorax should cause almost instant death. 

Morbid Anatomy. — The air in the pleural cavity is ordinarily 
pumped in through a single valve-like opening by the respiratory 
movements, thus creating marked intrapleural pressure. The lung is 
compressed in the direction of its root, mediastinal tissues are dis- 
placed towards the unaffected side, diaphragmatic movement is almost 
wholly abolished, the pleura becomes inflamed and in most cases a 
small amount of purulent, rarely a serous effusion, is present. 

Symptoms. — The onset is almost invariably sudden whatever may 
be the cause and follows directly upon injury, physical strain, vomit- 
ing, or, more frequently, a paroxysm of cough. Symptoms of shock 
are present, there is urgent dyspnoea, cyanosis and lividity, and the pa- 
tient ordinarily feels that there has been some "internal rupture." An 
insidious onset is rare and the author has observed but one such case. 
In such the opening is tiny and obstructed so that only the smallest 
quantities of air intermittently enter the pleural cavity. 

Physical Signs. — Inspection shows immobility and bulging of the 
affected side evidence of a displaced heart and unilaterally impaired 
diaphragmatic movement, the physiognomy of shock, cyanosis, and 
evidence of marked dyspnoea. Palpation confirms inspection and 
vocal fremitus is ordinarily greatly diminished or entirely lost. The 
percussion note is ordinarily distinctly tympanitic though under con- 
ditions of extreme pressure quite a marked degree of dulness may be 
found. Auscultation. Breath and voice sounds are feeble and distant 
or entirely absent. If the patient be raised to a sitting posture and 
gently shaken Hippocratic succussion is obtained. This is merely 
a splashing sound readily detected if the ear is applied to the chest 
during the manoeuvre and often heard at some little distance. An 
exquisite metallic tinkling is present in many cases as is the coin sound, 
obtained by placing the ear upon the chest wall anteriorly and having 
an assistant place a good sized silver or gold coin on the back and tap 
it with another, the conducted sound having a musical, bell-like or 
clear metallic ring. 

Cardinal Signs. — The three cardinal signs are: metallic tinkling, 
Hippocratic succussion, and the coin sound, but all of the signs are 
ordinarily so clear that an error in diagnosis can seldom occur. In 
cases where a large opening exists the signs arc those of an enormous 
cavity with firm smooth walls (see p. 103). In diaphragmatic hernia 



^ 



Lung com- 
pression. 



Symptoms 
urgent. 



Striking 
symptoms. 



Dulness 
possible 



J 



138 



MEDICAL DIAGNOSIS. 



Diaphrag- 
matic 
hernia. 



the history, borborygmi (rumbling, cooing) and the change of note 
on taking large quantities of water into the stomach or inflating it 
with air assist in differentiation. 

Course and Termination. — The course of pneumothorax depends 
chiefly upon its cause, and as those associated with chronic tuberculosis 
(90%) are almost invariably fatal, the mortality is enormous. 

HYDROTHORAX. — This is a serous pleuritic effusion without 
pleuritis and is a secondary ailment, usually bilateral, associated with 
cardiac and renal disease or terminal anaemias and cachexias. 

LOBAR PNEUMONIA— (Pneumonitis, Croupous Pneumo- 
nia, Lung Fever). — Definition. — An acute infection characterized by 
primary -fibrinous inflammation of the lobar type, profound toxcemia and 
an abrupt onset and termination. 

Germs. — Though found in normal buccal secretion and diseases 
other than pneumonia, Frankel's diplococcus pneumoniae or micro- 
coccus lanceolatus is believed to be the most frequent cause of the 
disease. It is present constantly in the saliva of some persons, and is 
found in the secondary processes of the disease. It is elliptical, the 
Suggestive lanceolates occurring in pairs and in sputum is ordinarily encapsulated.* 

Its marked resemblance to the meningococcus is interesting because 
of the coincidence of increased pneumonia incidence and mortality 
with epidemics of cerebro-spinal fever. 

Morbid Anatomy. — Three stages of the disease are recognized for 
purposes of convenience, but are often blended at autopsy. (1). 
Congestion. The lung is enlarged, dark red, less elastic than normal, 
on section frothy red liquid exudes, crepitation is impaired but sections 
will float on water. The microscope shows marked capillary tumes- 
cence and erythrocytes, leucocytes and desquamated epithelium. (2). 
Red hepatization (consolidation). The appearance is as in first stage 
but the lung does not crepitate, is friable, and sections sink in water. 
The cut surface is finely granular, the exuded serum is bloody (not 
frothy) and minute fibrinous plugs may be scraped from the surface. 
The microscope shows a coagulated fibrinous exudate and fibrinous 
threads holding in mesh great numbers of erythrocytes, leucocytes, 
and desquamated alveolar cells. There is marked round cell infiltra- 
tion of the interalveolar septa. (3). Gray hepatization (resolution) . 

* It is readily stained as follows: — (a) Make thin smear, dry in air and 
fix by heat, (b") Cover surface with the Hiss stain (gentian violet, satur- 
ated alcoholic solution 5 c.c. plus 95 c.c. distilled water), (c) Heat till 
steam rises, (d) Wash with copper sulphate solution (20%). (e) Dry and 
mount. The germ is Gram positive. 



Three 
stages. 



Conges- 
tion. 

Hepatiza- 
tion. 



Resolution. 



^=- 



LOBAR PNEUMONIA. 1 39 



1 



The gray color displaces the dark red of congestion and consolidation, 
the lung rapidly softens, becomes more crepitant, but is still friable 
and a purulent exudate follows the knife. As a result of the sub- 
sidence of inflammation and hyperaemia, liquefaction of the corpuscles Rapid 

J x ^ * changes. 

and fibrin takes place through a digestive ferment possessed by the 
leucocytes, the cellular elements undergo fatty and granular degenera- 
tion, and, within from two to four weeks, absorption taking place 
through the lymphatics together with free expectoration removes the 
inflammatory products. The duration of the stages of pneumonia is 
extremely variable. Consolidation may be complete in a few hours, 
but usually takes from 12 to 24. The hepatization period varies from 
three days to two weeks or more, from three to nine days being the 
usual period. The process of resolution is wonderfully rapid, and 
with its coming the whole complexion of the case changes in a few 
hours. 

Points of Importance. — The morbid anatomy makes clear the 
physical signs of the disease, but one should remember that areas con- 
tiguous to consolidation are hyperaemic and edematous and that bronch- Associated 
itis and pleurisy are invariable accompaniments of fully developed lobar 
pneumonia. Pleuritic effusion is comparatively slight and usually un- 
discoverable by physical examination. 

Predisposing Factors. — 60 or 70% of all cases occur in males and 
in the United States the colored people suffer more than the whites. | Males 
Children between the ages of two and six are especially susceptible 
and after an interval of relative immunity its incidence and mortality 
steadily increase from puberty to old age. Hence in incidence and Age. 
mortality it is a disease of the extremes of life. It is most prevalent in 
the late winter and early spring, is present in all civilized countries what- 
ever their latitude or climatic conditions, and is peculiarly fatal in some Season and 
high altitude regions, as in Butte, Mont., where the elevation and 
smelter fumes make it exceptionally deadly. Alcoholism, acute or 
chronic, is a marked predisposing factor unfavorably affecting prog- Habits. 
nosis and many acute "drunks" are brought to the police station suf- 
fering from an unrecognized pneumonia. Fatigue and exposure to cold Fatigue 
and wet if coincident are important factors, one attack invites others exposure 
and an astonishing number of recurrences have been reported in the 
same individual. Cold in itself must be regarded merely as a means 
of depressing vitality and lowering resistance and is more potent when 
combined with dampness. Coryza and bronchitis often precede an Anteced- 
attack, and no doubt furnish a favorable soil for the development oi 



1 



140 



MEDICAL DIAGNOSIS 



Compli- 
cating. 

"Typhoid.' 



Traumatic, 
migratory, 
massive. 



Afebrile 
and senile. 



Central. 



Terrible 
mortality, 



Increasing. 



Striking 
usually. 



the diplococci. Chronic disease may play a prominent part, and 
pneumonia is a frequent terminal event in acute or arrested pulmonary 
tuberculosis, chronic nephritis, diabetes, carcinoma, arterio-sclerosis, 
prostatic hypertrophy and chronic heart disease. 

Varieties of Pneumonia. — Pneumonia may complicate any acute 
infectious disease and is especially frequent in influenza. The term 
"typhoid" pneumonia should be confined to pneumonia with an over- 
whelming toxcemia which produces a typhoid state, not to pneumonia 
complicating typhoid fever. Traumatic pneumonia is rare, migratory 
pneumonias both unusual and interesting. Massive pneumonias are 
sometimes encountered in which the large bronchi are plugged and 
the physical signs greatly obscured by suppression of auscultatory 
phenomena. Afebrile pneumonia occurs especially in the aged, and it 
should be remembered that senile pneumonias may lack chill, high 
\ fever, cough, crisis, expectoration and typical physical signs. Central 
: pneumonias are very misleading, and it may be days before the 
process reaches the surface and yields physical signs of a positive 
nature. 

Delayed Resolution. — In the author's experience long delayed reso- 
lution is an extremely rare event, usually proving to be an empyema; 
but slow resolution is common, particularly in the lobar pneumonia 
of children. 

Selective Points. — The right lung is affected in about 60%, the left 
in 30%, and both in from 10 to 15% of all cases. As regards the 
lobes affected, apex pneumonia occurs in about ■£• of the cases and 
the whole lung is affected about as often as is the lower lobe alone, in 
which the inflammation usually commences. 

General Comment. — In these United States from 70,000 to 80,000 
of our people die each year of lobar pneumonia, and the disease is ap- 
parently increasing. As Osier says, it is the real "Captain of the Men 
of Death," and the true "friend of the aged." Its apparent increase 
may be due to more careful methods of diagnosis, but it is probable 
that other factors are operative. 

Symptoms. — The ordinary symptoms of pneumonia are (a). Chil- 
liness or repeated rigors, for which convulsions may be substituted in 
children, (b). Fever. Rising abruptly from normal to 103-105 F. and 
tending to assume a continuous form, it lasts throughout the period of 
congestion and hepatization (ordinarily from 3 to 14 days) and termin- 
ates by crisis, (c). Crisis. A critical drop in temperature and the 
dramatic contrast between intense suffering and relative comfort is an 



PNEUMONIA. 



I 4 I 



astonishing phenomenon. The fall usually reaches subnormal and is 
attended by sweating or perhaps diarrhoea. Immediately before it there 
may be a marked rise in temperature (pre-critical) ; following it there 
may be a secondary elevation rapidly subsiding to normal (post-critical). 
A pseudo crisis may occur and raise false hopes, and finally, an ante- 
mortem rise or fall may occur. The latter is most misleading, but is 
ordinarily associated with other signs of impending death that should 
prevent misconstruction, (d). Pain is almost invariably present and 
is distinctly pleuritic in type. (e). Cough and Expectoration. In the 
early stages the cough is dry, painful and unproductive, the sputum is 
at first scant and mucoid, then muco-purulent and blood-streaked, 
later, during hepatization, it becomes rusty and during resolution 
creamy, in appearance. The aptly named "prune juice" sputum is of 
serious portent and the sputum of the first two stages is so extraordi- 
narily tenacious as to cling to the lips and to the bottom of the inverted 
sputum cup. Respiration. Dyspnoea is always present, the respiration 
varying from 30 to 70 per minute, according to the extent of involve- 
ment and still more to the severity of the toxaemia, and the pleuritic 
pain causes a grunting respiration and shallow breathing. Heart and 
Pulse. The pulse is full and bounding, but as in typhoid, relatively 
slow. The pulse-temperature ratio and the condition of the heart 
sounds are important factors in prognosis. If the heart is acting prop- 
erly the pulmonary second sound is strongly accentuated and its marked 
diminution or absence points to right sided cardiac dilatation and im- 
pending failure* 

The Blood. — In pneumonia leucocytosis roughly measures the recip- 
rocal action of toxaemia and resistance and its absence is ominous. 
The average number of leucocytes is about 25,000 per cm., and counts 
between 30,000 and 50,000 are not uncommon. The significance of a 
failure of leucocytosis is somewhat diminished in complicating pneu- 
monias such as those associated with typhoid or smallpox, diseases in 
which the vitality of the patient may be greatly lowered. The leuco- 
cyte count ordinarily reaches normal within two or three days after crisis 
and its undue persistance suggests septic complications. The Urine. 
Albuminuria is common but is usually of the febrile type subsiding 
promptly with the termination of the active process. The urinary 

♦From clinical experience the author would advise special care in the 
Lobar pneumonia of arrested or apparently cured tuberculous cases. Many 
of these experience sudden collapse after a few days' illness and often at 
the time of apparent crisis. 



Critical 
signs. 



Rusty 
sputum. 

Prune juice 
sputum. 



Grunting. 



Prognostic 
signs. 



Leucocy- 
tosis the 
rule. 



Persistent 

leucocj 

tosis. 



A 



142 



MEDICAL DIAGNOSIS. 



Albumin 

and 

chlorides. 



Meteorism. 



Herpes. 
Alae nasi. 
Filush. 



Lagging. 



Increased 
fremitus. 



Confusing 
factors. 



chlorides are diminished or absent during the active stage of the disease 
and the urine is scant, dark, and of high specific gravity. 

Gastro -intestinal Tract. — The tongue is ordinarily furred, vomit- 
ing or diarrhoea may be present, and meteorism may greatly embar- 
rass circulation and respiration. 

Headache and Delirium. — Severe headache may be present at the 
onset or more rarely throughout the patient's illness. Delirium is 
unusual, the patient being ordinarily rational and acutely sensible of 
his situation and either low or active delirium is ominous. Maniacal 
delirium occasionally occurs, and delirium tremens frequently develops 
in alcoholic cases.* 

Physiognomy of Pneumonia. — If the patient be conscious, the 
expression is anxious, eye bright, the attitude active, and the decubitus 
usually lateral, the affected side being most often undermost during 
the early stages. Herpes appear on the lips in a majority of cases and 
dyspnoea is evident both in the chest movement and the working 
nostrils. Both cheeks may be flushed, or that of the affected side 
alone and more or less cyanosis is always present. Deepening cyanosis 
should be carefully watched for and met by appropriate treatment 
directed to the circulation. 

Physical Signs. — Inspection. — Aside from the physiognomy and 
decubitus one notes lagging or immobility of the affected side as a 
whole or chiefly over the lower zone if the base only be involved, in- 
creased rate of respiration and overaction of the accessory muscles of 
respiration. 

Palpation. — Confirms inspection and if fremitus is tested after 
cough (to remove obstructive secretion) it will be increased unless the 
larger bronchi are filled with fibrinous exudate (massive pneumonia). 
Pleural friction may be felt in some cases and palpatory percussion 
reveals marked resistance over the affected area. 

Percussion. — Dulness with well marked resistance is the sign of 
consolidation, hyperresonance or tympany that of engorgement, and in 
early or doubtful cases percussion should be made while the patient is 
lying prone, or, if deemed safe, sitting up and leaning forward to avoid 
confusing differences due to the unequal thoracic pressure involved in 
the lateral position. Percussion may be wholly negative in central 
pneumonia for several days but is so frankly dull, ordinarily (when 
hepatization is established), as to require no precautions as to posture 
and leave no doubt in the mind of the examiner. Equally clear is the 

* Too frequently the pneumonia is overlooked in such cases. 



PNEUMONIA. 



143 



hyperresonance above the dull area (advancing infiltration — vicarious 
emphysema — impaired tonus) which may even simulate the cavity per- 
cussion note in quality and variations, especially in cases of apex 
pneumonia. 

Auscultation. — In the first stage, or in massive pneumonia, the 
breath sounds may be suppressed and one should seek to hear the true 
crepitant rale at the end of inspiration. As the consolidation advances 
and nears the surface the intensity and bronchial character aj the sounds 
increase pari passu until exquisite, dry, tubular breathing is audible over 
the area of consolidation however varied may be the rales over adjacent 
areas or in the opposite lung. 

The voice sounds may be normal or diminished early, but, as a rule, 
give better and prompter news of an advancing process than do the 
breath sounds, and ultimately yield the pure broncophony of super- 
ficial consolidation. As in palpation, if the signs are obscure, the pa- 
tient should cough to clear the bronchi before auscultation is completed. 
In the stage of resolution there is a rapid recession of the pure tubular 
breathing and voice conduction, associated with the reappearance of 
fine crepitation, shortly succeeded by coarser moist rales, together with 
diminishing percussion dulness and fremitus. 

Diagnosis. — Diagnosis depends upon the frank, febrile onset and 
continuous high fever, pulse temperature ratio, rusty sputum and phy- 
sical signs, and the sputum is often characteristic when physical signs 
are lacking (central cases). The only confusing conditions are afebrile 
senile pneumonias in which the physical signs and toxaemic symptoms 
must govern; cases of pleural effusion with transmitted tubular breath- 
ing, differentiated by the flatter percussion note, displacement of the 
heart, more distant quality of the tubular breathing and relatively 
slight fremitus, and, positively, by the exploratory hypodermic puncture 
and removal of the fluid; cases of acute pneumonic tuberculosis, in which 
an existing or pre-existent lesion or a tainted family history may be 
suggestive, but which can often be differential ed only by the subsequent 
course, evidences of a destructive process and the recovery of the 
tubercle bacillus from the sputum; hypostatic pneumonia occurring in a 
febrile disease, in which case the primary condition itself usually sug- 
gests the probability of hypostasis which is often incomplete, usually 
bilateral, markedly and persistently dorsal, and in correspondence 
with and dependent upon the decubitus of the patient and heart 
strength. 

Broncho-pneumonia is wholly different as to course ami sputa. 



Hyper- 
resonance. 



Value of 
crepitation. 



Voice 

sounds best 
guide. 



Usually 
easy. 



Misleading 
conditions. 



Explora- 

tor> 

puncture. 



1 1> DO- 



J 



144 



MEDICAL DIAGNOSIS. 



Usually 
unlike. 



Usually 
detected. 



Important 
factors. 



Heart and 
respiration. 



Essential 
element. 



and in physical signs, save in the exceptional cases of extensive fusion 
of broncho-pneumonic areas, and in these the course and associated 
and antecedent pulmonary signs are sufficiently distinctive. Infarct 
is usually suggested by the primary disease with which it is associated, 
its instantaneous onset and limited area, bright bloody sputum or actual 
hemoptysis. 

Finally. — Central pneumonia which may not be positively diagnosed 
until rusty sputum appears or the signs become evident from super- 
ficial consolidation, but as a matter of fact usually is recognized at 
least tentatively before these evidences appear, even in its larval forms, 
by its onset and the suggestive though not clean-cut localized departures 
from normal physical signs. 

Prognosis. — Pneumonia is an extremely fatal disease and kills from 
10 to 70 or even 80% of the cases affected, according to the virulence 
of the type and the age and vitality of the individual. The outlook 
is bad at the extremes of life, in the obese, in those of bad habits and in 
such as are debilitated by overwork, unfortunate sanitary environment 
or chronic disease. The tuberculous experience a high mortality, 
and recurrent cases are somewhat more dangerous than primary attacks. 
Influenzal pneumonia of the lobar type is especially fatal though some- 
times peculiarly transient. Excessive rapidity and arrhythmia both 
as affecting pulse and respiration are ominous signs, as also are extreme 
cyanosis, absent or markedly diminished pulmonary second sound, profound 
albuminuria, low leucocyte counts, and marked delirium. In a high class 
private practice at least 10% of all cases die, in general hospital practice 
the mortality will vary from 20 to 40%. In patients above 60 years 
of age § will die.* The essential element in prognosis and treatment 
consists in the appreciation of the fact that one is dealing with a toxaemia 
to which all local manifestations are secondary, and that hope lies in 
diminishing its virulence, and increasing the natural resisting power of 
the patient. 

BRONCHO-PNEUMONIA. — (catarrhal pneumonia, lobular 
pneumonia, capillary bronchitis.) 

Definition. — An acute mixed infection associated with profound 
toxcemia and an inflammation having its seat primarily in the terminal 
bronchioles and lobular tissue of the lung. 

Etiology. — No special germ has been identified, but the diplococcus 

* So many variations enter into both private and public practice that 
arbitrary figures become ridiculous and our judgment must depend upon 
a knowledge of the favorable or unfavorable factors in each case. 



^ 



BRONCHO-PNE UMONIA. 



145 



pneumoniae is most often found, usually in connection with other germs, 
such as the pyogenic streptococci, Friedlander's bacillus and more 
rarely Klebs-Lcefiier and influenza bacilli. The general predispos- 
ing factors are essentially the same as in lobar pneumonia (see p. 139). 
75% of an< pneumonias in children are of this type and of these 
about § follow bronchitis. It is very common in the aged and as a 
complication of acute and chronic disease. Any irritant, as irritating 
fumes or dust, the vapor of anaesthetics or the aspiration of food particles 
may cause it in the presence of pathogenic germs. 

Morbid Anatomy. — The first stage is one of intense congestion and 
the capillary bronchiolitis and alveolar congestion is followed by a sero- 
fibrinous or hemorrhagic exudation associated with pronounced desqua- 
mation of epithelium. Ordinarily an antecedent bronchitis extends to 
these structures, the bronchioles become plugged; the alveoli gradually 
lose their contained air and collapse. The exudate, ordinarily termed 
catarrhal, is sometimes distinctly fibrinous but 
its cellular constituents show a predominance of 
epithelium over leucocytes. The process is 
bilateral, affecting chiefly the lower lobes poste- 
riorly; the lung appears mottled with bluish 
brown airless depressions indicating collapsed 
areas, interspersed with bright red emphyse- 
matous and crepitant fields. Fusion of areas 
may bring about extensive consolidation or the 
affected portions mav remain isolated and are 
sometimes so minute as to constitute an acute 
miliary broncho-pneumonia. Collapsed areas 
may be distended by the blow pipe, the lungs are larger than normal, 
have a nodular feel, and drip on section and the process of resolution is 
much the same as in lobar pneumonia, but is unfortunately more irreg- 
ular in its points of development so that the disease ordinarily terminates 
in protracted lysis. 

Two Chief Divisions of Broncho-pneumonia. — The disease 
may be divided into primary and secondary cases. The former come on 
acutely and terminate as a rule quite abruptly, the latter are invariably 
subsequent to a bronchitis or complicate some existing disease. The 
primary type is infrequent in patients over 4 years of age but consti- 
tutes about £ of the cases in children. The primary congestive form 
may kill in from 12 to 24 hours or may terminate favorably in a few 
days. The secondary form lasts for weeks. 




Mixed 
infection. 



Fjg. so. — Diplococcus 
Pneumoniae. (Frankel- 
Weichselbaum) and the 
pneumo-bacillusof Fried- 
laner. Upper segment 
shows former, lower seg- 
ment shows latter. 



Bronchio- 
litis. 



Catarrhal 
exudate. 



Bilateral. 



Fusion 
of areas 



Miliary 
form. 



Primary 

\ s. 
Secondary 



J 



146 



MEDICAL DIAGNOSIS. 



Signs 
posterior. 



Pulmonary 
at onset. 



Rapid. 



Sudden 
onset. 



Toxaemia 
profound. 



Low fev< 



Basal 

signs. 



Hyper- 
resonance. 



Sub-divisions. — Aside from the general division into primary and 
secondary cases, we recognize three forms of disease, (1). An acute con- 
gestive broncho-pneumonia. (2). Disseminated broncho-pneumonia, often 
described as capillary bronchitis, and (3). The common form* of the 
disease. 90% of forms (1) and (3) are bilateral, the disseminated form 
invariably so. In the acute congestive and the common form, the 
signs are always most marked posteriorly and nearly always in the in- 
terscapular spaces. Save in the acute congestive pneumonias, the symp- 
toms and physical signs are strikingly pulmonary from the outset, though 
sometimes obscure, confusing, and out of accord with the degree of 
involvement shown by autopsy in fatal cases. The nature of the 
pathologic process explains this fact by showing that even where con- 
solidation exists the condition of the surrounding tissues may be such 
as to produce a hyperresonance which masks the percussion signs of 
consolidation. 

Symptoms of the Acute Congestive Form. — This may be rapidly 
fatal, killing in 24 or 48 hours and the physical signs may be limited to 
harsh breath sounds and possibly a slightly impaired percussion note. 
i The signs are usually bilateral but not necessarily of equal intensity. 
The onset is sudden, often with vomiting and occasionally with convul- 
sions in children or chill in the adult. The fever runs high and may 
steadily increase to a fatal termination (103-107). Cough may be 
entirely absent or violent and harassing. Pulse and respiration are 
extremely rapid, cyanosis marked, menial didness and apathy early and 
extreme. It may merge into the common form of the disease or term- 
inate sharply by crisis. 

Acute Disseminated Broncho-pneumonia. — This form which 

some of the foreign clinicians still term "capillary bronchitis" is primarily 

an inflammation of the capillary bronchi, but, post mortem, is invariably 

associated with areas of true broncho-pneumonia. Like the other 

forms it comes on acutely, pulse and respiration are rapid, prostration 

is marked but not immediate, dyspnoea and cyanosis are prominent, the 

cough is severe though not sharply painful, but the temperature usu- 

j ally runs low. The physical signs consist chiefly of the sub-crepitant 

j and coarser rales, generally distributed, always bilateral, and best 

I marked posteriorly at the bases. The percussion note is hyperresonant 

or even tympanitic, and the disease ordinarily runs a short course of a 

few days or a week or ten days and terminates by lysis, or merges into 

the common form of the disease. Recovery is the rule. 

* Following Holt's classification. 



BRONCHO-PNEUMONIA. 



147 



^ 



Symptoms of the Common Form. — The onset is abrupt, fever high 
but with rare exceptions strikingly remittent (often 3 to 4 degrees), 
vomiting is frequent and convulsions in children a rare initial event. 
Cough is early, intractable and persistent, harassing but not usually 
painful. The respiration is rapid (60-80 or even 120 in severe cases) 
and may be noted as a premonitory symptom even before the frank onset; 
prostration is marked and shortly becomes extreme; expectoration is 
absent in children, cyanosis becomes marked in all severe cases, and 
late convulsions may occur as one of the terminal events. In rare 
instances infants or badly nourished children may show a low temper- 
ature. The pulse may reach 200 and is always rapid and some- 
times irregular, the signs of actual dyspnoea are pronounced, the alae 
nasi being active and inspiratory recession of the lower interspaces 
marked. Gastro-intestinal disturbances may be present and greatly 
complicate the treatment, flatulence and exhausting diarrhoea 
or persistent vomiting aggravated by cough being the most trouble- 
some factors. The urine is febrile, being scanty, high colored, contain- 
ing excess of urates and perhaps a trace of albumin. The ordinary 
course is from two to three weeks and it usually terminates by lysis. 
Cases may however be prolonged for two or three months or a chronic 
broncho-pneumonia may succeed the acute form and often develops 
into a tuberculosis. 

Physical Signs. — These are primarily the signs of an acute bronchio- 
litis, the most characteristic sign being the subcrepitant rale heard 
chiefly and predominantly over the lower lobes in the interscapular 
spaces. Unlike lobar pneumonia the left lobe is usually chiefly affected 
though both are involved. Bronchial rUes, dry and moist, of a larger 
and coarser character may mask the finer crackles and after a variable 
period evidences of consolidation may appear over scattered areas or 
more rarely produce extensive consolidation. 

Inspection. — Inspection reveals the fades of profound illness and its 
pulmonary type is indicated by the evident dyspncea, harassing cough. 
slight or marked cyanosis and inspiratory recession of the lower inter- 
spaces. Palpation is negative in the congestive type, fremitus is dimin- 
ished in the disseminated but may be increased in the "common form" 
if consolidation be sufficiently extensive. Percussion is negative in the 
congestive form or shows only slight dulness, there is Jiyperresonanee 
or tympany in the disseminated variety, while in the common form scattered 
areas of impaired resonance may alternate with Jiyperresonanee. Further- 
more, certain areas may disappear and reappear from day to day. 



Marly rapid 
respiration. 



Rapid 
pulse. 

Dyspnoea. 



Gastro- 
intestinal 
symptoms. 



Termina- 
tion. 



Left lobe 
chiefly. 



loo sick for 

bronchitis. 



\ a elu- 
sions. 



VJ 



148 



MEDICAL DIAGNOSIS. 



Use light 
percussion. 



Most 

valuable 

procedure. 



Crying 
assists. 



Serious 
complica- 
tions. 



Persistent 
cough. 



Tubercu- 
losis. 



Usually 
secondary 
and sub- 
ordinate. 



or hour to hour. Light percussion should invariably be practised and 
it should be remembered that consolidation areas are first and chiefly 
evident in the interscapular spaces save in those instances, usually tuber- 
cular, in which the localization is anterior and apical. Auscultation is 
by far the most valuable procedure. The characteristic subcrepitant 
rales are evident, overshadowed perhaps by their coarser brethren, and 
areas of increased voice conduction and harsh or even tubular breathing 
may make consolidation manifest to the ear even though it is not to the 
percussing finger. Friction sounds are rare and it should never be for- 
gotten that all signs may be lacking save in forced deep inspiration, often 
obtainable in children only through the act of crying, and furthermore, that 
in all cases of broncho -pneumonia the patient is too sick for a simple 
bronchitis which the disease may simulate in its early stage or may directly 
follow. 

Secondary broncho-pneumonia is a common event in certain of 
the acute exanthemata, especially measles, scarlet fever and diphtheria, 
and as a terminal event in cachexias and senile conditions. In the latter, 
its course may be insidious and lacking in the franker clinical mani- 
festations. In measles and scarlet fever it is severe and protracted, in 
diphtheria extremely fatal. In influenza one meets with two types, 
one extremely brief, the other protracted and severe. The latter form 
is peculiarly liable to leave behind it a persistent spasmodic cough. 

Complications. — Ileo-colitis is dangerous and troublesome when it 
occurs. Meningitis and nephritis are rare, tuberculosis is not uncom- 
mon and is undoubtedly often primary. Endocarditis is fortunately a 
clinical curiosity. Suppuration and abscess formation are rarely seen 
save in aspiration and deglutition cases. 

Termination. — Many cases are prolonged for months with recur- 
ring attacks and some ultimately recover though many prove tubercu- 
lous and run the course of a chronic tuberculosis or of fibroid phthisis. 

ATELECTASIS.— Definition.— A condition characterized by local- 
ized or extensive, temporary or persistent, loss of the pulmonary air 
content. 

Etiology.— Aside from atelectasis in the new-born child resulting 
from extreme weakness or actual obstruction from meconium or mucous, 
the condition is essentially secondary to obstruction of the bronchi, large 
or small, i.e. broncho-pneumonia, obstruction by tumors, membrane, 
foreign bodies, or the pressure of growths or exudates, i.e. mediastinal 
or pleural growths, pleural effusion, pneumothorax, greatly enlarged 
heart, pericardial effusion, etc. Slight grades result from mere deficient 



CONGESTION OF THE LUNGS. 



149 



^ 



expansion, as in adenoids, enlarged tonsils or in delicate women and 
children. In extreme cases the lung is carnified and persistent atelec- 
tasis leads to atrophy or fibrosis. 

Diagnosis. — The presence of an adequate cause, inspiratory recession 
of interspaces or actual retraction, absent or distant tubular breath 
sounds and corresponding fremitus make the condition clear. These 
are for the most part silent or hushed areas though in cases of broncho- 
pneumonia deep inspiration may convert them into noisy ones. The 
condition is so generally secondary and subordinate as to require no 
extended notice here. 

CONGESTION OF THE LUNGS.— Active congestion and the 
three forms of passive congestion which include so-called pulmonary 
edema will be discussed under this head. 

Active Congestion. — The inhalation of irritating substances chiefly 
vapors and gases and the primary stage of pneumonia are the chief 
factors in the production of an extensive, active congestion and it is 
so generally but a stage in a dominating disease process as hardly to 
deserve extended description. (See lobar pneumonia, p. 138.) 

Passive Congestion. — Sharply drawn lines between obstructive 
and hypostatic congestion and between these and pulmonary edema 
are unfortunately largely confined to the autopsy room. Between the 
two former there is little need of distinction for both arise from an 
obstructed circulation whether from valvular disease, a weakened 
myocardium, toxaemia, the pressure of tumors, pleuritic or pericardial 
exudate or abdominal distention, or from cerebral lesions. Clinically 
the hypostatic form as opposed to the simple obstructive congestion is 
encountered in conditions of profound exhaustion especially such as are 
characterized by the typhoid state, i.e. it represents profound aesthe- 
nia. Edema accompanying acute congestion or inflammation is termed 
inflammatory as opposed to the ordinary edema of the lungs associated 
with passive congestion. This latter form is a terminal event in 
many diseases and may come suddenly and without warning or 
supervene upon prolonged congestion. In certain cases it seems to be 
purely toxaemic but in general its etiology is that of the associated 
congestion. 

Morbid Anatomy. — Long continued passive congestion may pro- 
duce brown induration, the organ being dense, bulky and russet brown; 
its capillaries are distended, the bronchioles and alveoli filled with epi 
thelium, blood cells and pigment, and there is connective tissue in- 
crease. This represents especially the obstructive congestion typified in 



Adenoids 

and the 

like. 



Dubious 
distinction 



^ 



w 



ISO 



MEDICAL DIAGNOSIS. 



Seek cause. 



Slight 
symptoms. 



incompensated mitral lesions. In the hypostatic form the engorgement 
is intense and portions of the lung sometimes airless. If these areas 
are extensive the term splenization is applicable. In edema the bulky 
lung is sodden and the foamy yellow or reddish serum infiltrates the 
interstitial tissue and fills the air passages. Any of the forms of passive 
congestion may be predominantly unilateral but are usually bilateral. 

Diagnosis. — The existence of a cause is the first link in the dubi- 
ous chain. The symptoms of acute congestion of the severer form are 
described under pneumonia. The milder types of all varieties may 
produce but slight subjective and objective symptoms. In cardiac 
disease for example the condition may not attract notice until there is 
marked dyspnoea and a blood streaked sputum containing the peculiar 
pigment bearing cells. A careless practitioner often entirely overlooks 
hypostasis until it has reached a pneumonic stage (splenization). Less 
frequently mild forms of edema occur which may be transitory. In 
the severer forms of passive congestion dyspnoea and cyanosis are 
present and in marked edema are excessive. In all there is restriction 
of chest movement pari passu with the area involved. Fremitus may 
be diminished or increased according to the degree of actual consolida- 
tion present The percussion note may be hyperresonant from relaxa- 
tion or dull from consolidation. Auscultation may reveal harsh, dimin- 
ished, absent or tubular breathing according to the stage of congestion, 
the presence of atelectasis or, true consolidation. Rales, both dry and 
moist are present, their pitch and quality varying with the pathologic 
conditions. In edema the subjective symptoms are especially pro- 
nounced, the sputa profuse, frothy, serous or blood stained and in in- 
flammatory edema present the " prune juice" appearance. In edema, 
moreover, the rales are more liquid, the breath sounds and voice con- 
duction suppressed or feeble. Slight crepitation at a base in a nephritic 
subject, or any patient suffering from the diseases associated with 
passive congestion, demands serious attention. Astonishingly sharp 
congestions may accompany obscure apoplexies unassociated with pa- 
ralysis or loss of consciousness.* The effect of cardiac stimulation 
or, in hypostasis, mere attention to the necessary shifting of a patient's 
position may rapidly and markedly diminish the involved areas, the 



Variable 
physical 
signs. 



Marked 
subjective 
and objec- 
tive signs. 



Test man- 
oeuvres. 



* In a case recently observed two cerebral hemorrhages of the silent type 
occurred without loss of consciousness or power, the only symptoms being 
sudden pallor, mental confusion and- in the second attack transient motor 
aphasia. In each there was marked pulmonary congestion lasting for 
about 12 hours. A third hemorrhage ten days later produced almost in- 
stant death. 



TUBERCULOSIS. 



151 



latter condition being often due to one fixed posture in senile, obese, 
cachectic or profoundly toxaemic patients. 

TUBERCULOSIS. (Pulmonary phthisis, consumption).— Defini- 
tion. — An infectious disease caused by the tubercle bacillus oj Koch, 
usually chronic, rarely acute, characterized by the formation of tubercles 
or a diffuse infiltration of tuberculous tissue and tending to ulceration, 
fibrosis or calcification. 

Distribution. — It is a universal disease visiting practically all races 
and every latitude. In the United States alone it kills at least 150,000 
persons each year, and the annual loss in potential wealth has been 
estimated at $500,000,000. It costs the life insurance companies of 
America at least $6,000,000 annually, and as the deaths occur chiefly 
at early ages when few premiums have been paid, it constitutes the 
source of their greatest early loss. Domestic animals and pets, such as 
cattle, pigs, guinea pigs, rabbits and monkeys are extremely susceptible; 
horses, dogs, goats and cats less so. Cold, damp, densely populated 
districts suffer most, and dry and high altitude regions least. 

Morbid Anatomy. — If a pure culture of tubercle bacilli be injected 
in the tissues of a susceptible animal it produces tuberculosis. From 
the tuberculous tissues the germ can be recovered, grown in pure cul- 
ture, again used for inoculation and so on indefinitely. This absolute 
proof of its infectious nature makes the position of those fighting the 
"great white plague" unassailable. Changes Subsequent to Inoculation. 
(a). Grouping of germs in tissue by multiplication and their distribu- 
tion by the lymph current, (b). The formation of epithelioid cells, 
about five days after inoculation, by multiplication and by metamor- 
phosis of the cells of the capillary endothelium and connective tissue, 
(c). Outwandering of leucocytes to focus of infection and multiplication 
of mononuclear forms, (d). The formation of a marginal reticulum of 
connective tissue, (e). The production of large epithelioid cells con- 
taining from four to twenty nuclei grouped at the poles or periphery. 
These giant cells are most common in lupus and in glandular and bone 
tuberculosis and the more chronic and slowly developed the process, 
the greater is their number. In acute lesions they are scant and ab- 
sent, nor are they peculiar to tuberculosis, being found in other of the 
granulomata such as syphilis. Caseation and Sclerosis. The changes 
described tend inevitably to devitalize the affected tissue and produce 
areas of central coagulation necrosis converting all structures into a 
cheesy homogeneous substance. This may be extruded, leaving cavi- 
ties of greater or lesser size, or, more rarely, calcification may accom- 



An unnec- 
essary 
scourge. 



Suscepti 
bility. 



Cause 
proven. 



152 



MEDICAL DIAGNOSIS. 



Slow 
vs. 
Rapid. 



pany encapsulation. Many cases terminate spontaneously without 
reaching caseation and often without yielding any recognizable 
symptoms. 

The Spread of Infection. — It will be readily understood that 
lymph distribution means a slow infection and infection through the 
blood stream a rapidly developing and widely disseminated process. 

Etiology. — Race. The Hebrews are to a certain extent immune, 
but in this country the Irish and the Scandinavian, the Indian and the 
Negro show a heavy mortality. Sex. Its incidence is about equal 
in the two sexes. Age. Children are peculiarly prone to affections of 
the glands and bones. After the age of childhood the lungs are chiefly 
affected and susceptibility diminishes considerably at the age of 30. 
Occupation. Occupations involving exposure to extremes in temper- 
ature, dust and dampness are distinctly unfavorable. Workers grinding 
glass or steel or handling furs show a high mortality. Sanitary Con- 
ditions. Lack of sunshine, fresh air, overcrowding, filth and physical 
exhaustion are all predisposing factors. Amongst the tenement classes 
all conditions are favorable to its development and transmission. Pre- 
existing Diseases. Tuberculosis frequently follows chronic disease 
of the tonsils, adenoids, neglected colds, broncho -pneumonia, lobar 
pneumonia, pleurisy, influenza, measles, whooping cough and entero- 
colitis, and may complicate diabetes, aneurism, heart disease, locomotor 
ataxia, sclerosis of the liver or chronic Bright's disease, any condition 
in short reducing vitality and resistance or tending to prevent free lung 
expansion. Injuries. Tuberculosis of the bones and joints and espe- 
cially of the vertebra and hip joints in children is frequently ascribed 
to injury though due no doubt to a pre-existing latent infection. 
Heredity. Direct transmission in utero is probably extremely rare, and 
heredity is but another name for post-partum implantation of germs 
upon a fallow soil. The tuberculous mother readily transmits germs 
to her offspring and a neglect of sanitary precautions in any infected 
house is peculiarly dangerous to the children. The germs may remain 
latent in the glandular system for an indefinite period, a fact undoubt- 
edly explaining the increased adult mortality from tuberculosis in 
families showing the taint. Individual Predisposition. The "habitus 
phthisicus" has long been recognized, certain individuals being from 
birth less resistant to the germ than are others. Small bones, a deli- 
cate complexion, and a contracted chest, long sweeping lashes, large 
lustrous eyes and silky hair are found in one type; a muddy complexion 
with marked tendency to glandular swelling, acne and weak eyes mark 



Common 
factors. 



Diminished 
resistance. 



Means 
post- 
partum 
infection. 



Often 
latent. 



Known 
types. 



TUBERCULOSIS. 



153 



Previous 



the other type. Extraordinary beauty, unusual intelligence and a quick 
wit were recognized even by the ancients as qualities often associated 
with tuberculous predisposition. The children of either type represent May 
undoubtedly cases of latent infection and need unusual care along disease 
hygienic lines. Having this, they may grow up to manhood strong and 
well, and die of old age. 

Preferential Site of Lesions. — Almost any portion of the body 
may be involved, the lungs most frequently in adults, the bones, lymph 
glands and intestines in children, while the peritoneum, kidneys or 
brain may be involved at any age. Secondary involvement of the in- 
testines is very common in advanced pulmonary tuberculosis. 

Modes of Onset. — It should never be forgotten that nearly every 
case of tuberculosis, whatever its form, gives a history of previous impair- 
ment of health. As regards actual onset, it may be acute miliary and r 
widespread, or wholly glandular, pleuritic or pneumonic. 

ACUTE MILIARY TUBERCULOSIS.— (Acute tuberculosis. 
General diffuse tuberculosis. Acute disseminated tuberculosis.) 

Cause. — Introduction of tubercle bacilli, from a latent or active 
glandular, osseous, or pulmonary focus, into the blood stream. 

Morbid Anatomy. — Viscera show general changes of an acute 
febrile infection and a general distribution of miliary tubercles, the 
lesions in the lung, pleura or brain predominating and the peritoneum 
or more often its diaphragmatic surface being frequently affected. 

Symptoms. — Typhoidal Form. The onset may be gradual and 
exactly simulate typhoid. The fever rises gradually or more rarely, 
sharply, and to a variable degree, 103-105 F. being common and 
afebrile cases rare. The symptoms may be those of the "typhoid 
state" but the following are prominent and should be carefully noted: 
— (a). Markedly accelerated breathing, (b). Subjective and objective 
dyspnoea, (c). A rapid weak pidse. (d). Cyanosis, (e). Sweats, (f). 
A variable, often intermittent or inverse temperature. A continuous tem- 
perature may be present for some days prior to the development of 
intermittency. Usually but not invariably one observes (g). cough 
unproductive or attended by purulent or muco-purulent sputum, (h). 
Tubercle bacilli, which may be present early, more often late, or. in rare 
instances, be absent throughout, (i). Herpes labial is. (j). Rapid 
emaciation is constant. 

Physical Signs. — At first they are absent or only bronchitic in 
character and for days or weeks may be scant or misleading. 
A careful examination may demonstrate the presence oi ante- 



Important 
signs. 



Bacilli may 

be absent. 



scant. 



154 



MEDICAL DIAGNOSIS. 



Hyper- 
resonance. 



Usually 
broncho- 
pneumonic. 



Early 

diagnosis 

difficult. 



Later, is 
evident. 



Bacilli 

often pres- 
ent early. 



cedent tuberculous lesions. The author believes that hyperresonance is 
the most constant and significant early sign. In rare instances 
patches of consolidation are clearly denned. The enlargement of the 
spleen occurs much later than in typhoid, and the same may be said o] 
Ehrlich's diazo -reaction. WidaVs test is absent, and the stools are 
quite unlike those of typhoid. Furthermore the pulmonary symptoms 
are strikingly predominant even in that acute general form which pre- 
sents abdominal symptoms.* 

Course. — Six to twelve weeks. Prognosis. — Almost invariably 
fatal, though rarely the acute symptoms subside leaving a progressive 
but limited lesion. Comment. — The general symptomatology of the 
disease is that of an acute intoxication with disseminated miliary foci 
and these facts explain the absence of marked physical signs. Cases 
may be wholly pulmonary or predominantly abdominal, but a division 
into pulmonary, typhoidal and peritoneal is useless. 

ACUTE PNEUMONIC TUBERCULOSIS.— (Phthisis florida, gal- 
loping consumption, acute tuberculo-pneumonic phthisis). This is a 
relatively rare disease representing not over 2% of the cases of pulmon- 
ary tuberculosis. It is usually broncho-pnemonic in form; rarely, lobar. 

The lobar form may exactly simulate an ordinary pneumonia, but 
one finds ordinarily a history of previous illness or signs of old lesions. 
In these cases the destructive process is often 
rapid and extreme and the author recalls one in 
which at autopsy the right lung was found to be 
entirely destroyed, leaving a huge cavity; the left 
infiltrated and hypertrophied to such an extent 
as to force the heart to the right and produce a 
concentric dexiocardia. Instead of a true crisis, 
septic temperature develops with sweats and a 
purulent sputum containing tubercle bacilli but 
in some instances the process subsides, becomes 

chronic and may even become arrested. Early positive diagnosis is 
usually impossible. 

The broncho-pneumonic form, is characterized pathologically by 
broncho-pneumonic lesions and shows a tendency to fusion, caseation 
and cavity formation. It presents the symptoms of an acute broncho- 
pneumonia followed by the signs of septic absorption, pulmonary infiltra- 

* As a matter of fact the confusion of typhoid fever and miliary tuber- 
culosis need but rarely occur even if the diagnosis lack the assistance of the 
Widal test. 




Fig. 51.— Tubercle 
bacilli in sputum. 



TUBERCULOSIS. 



155 




Hon and cavity formation. Tubercle bacilli may be and usually are 
present early but their appearance may be delayed. Hemoptysis may 
occur and is sometimes the first event. 

Comment. — In both the lobar and broncho-pneumonic forms of 
acute tuberculosis a delayed diagnosis is almost always necessary, the 
most careful questioning as to previous health and family history may 
yield no information, and the appearance of tubercle bacilli and the 
signs of destructive infiltration associated with hectic may be the only 
means of diagnosis. 

CHRONIC ULCERATIVE TUBERCULOSIS.— Definition.— A 
tuberculous disease of the lung characterized by chronicity, variability 
in severity and frequent intermissions. Aside from individual resist- 
ance, its termination in recovery or death depends upon the prompt- 
ness with which a diagnosis is made and rational measures instituted. 
Pathologic Anatomy. — The lesions are ordinarily those of a chronic 
tuberculous broncho-pneumonia; the terminal bronchioles and the alve- 
oli being the seat of an inflammation forming 
areas of peri -bronchial pneumonia; subse- 
quent changes depending upon the activity 
of the process and the resistance of the indi- 
vidual. Usually a fusion of areas results in 
ulceration and cavity formation. Favorable 
cases result in fibrosis, capsular limitation 
and arrest more often than is ordinarily sup- 

pfenlr^Cavhies 8 ; IncfpieSt P osed > spontaneous recovery from unrecog- 
Tubercular Deposits; Area of n { ze ^ tuberculosis being common, as shown 
boftening (.Right Interior). ° 

by the post mortem records at home and 
abroad, contracted apices, peri -bronchial nodules and adhesions being 
frequently found. Inflammation of lung tissue in this disease leads to 
pleuritis and limitation of lung movement. The areas involved furnish 
the signs of broncho-pneumonia either sharply localized or dissemin- 
ated, but large tracts may become involved with a corresponding in- 
crease in the frankness of the pulmonary symptoms. By necrosis of 
the bronchial walls through inflammation aided by the pressure oi re- 
tained secretion and a destructive ulceration, cavities arc formed, the 
physical signs of which are fully discussed on page go. New cavities 
without a firm limiting membrane may yield doubtful signs, particu- 
larly if they occur in the center of a caseous area lacking bronchial 
communication. Vomica vary in size, sometimes representing almost the 
whole right or left chest as in the ease mentioned on page 154. Small 



The sine 
qua non. 



Fusion 
of areas. 



Fibrosis. 



l'leurit 



C avitj 
Formation 



«6 



MEDICAL DIAGNOSIS. 



Haem- 
optysis 



Bronchi- 
ectasis. 



Early 
diagnosis. 



Curability. 



Progressive 
loss. 



Common. 



Often 
denied. 



Often 
absent. 



Variable. 



Seldom 
extreme. 



cavities are obliterated by a process of absorption, fibrosis and contrac- 
tion ; large cavities may be partially obliterated by the same processes 
and become inactive. Hemorrhage may occur at any stage of a chronic 
ulcerative tuberculosis and though the arteries are usually resistant, 
may be the first symptom. The amount varies from a mere streak of 
blood to the rare flooding that kills almost instantly. Bronchiectases are 
common in advanced cases, the intestines are often involved and this 
complication, like ulceration of the larynx, is painful, exhausting, and 
tends to greatly shorten life. 

Symptoms. — Early symptoms. The modern theory of the curability 
of tuberculosis depends upon early diagnosis. Every physician knows 
that cases referred to him as latent or incipient are likely to be far 
advanced, i.e. in the second or even third stage of the disease. They 
should be recognized before the stage of extensive infiltration and certainly 
before softening has begun if the best results are to be obtained. When 
so recognized at least 80% can be restored to apparent good health, 
and the larger number of these should remain well under proper con- 
ditions. Aside from tubercle bacilli and cavity signs no one symptom is 
conclusive, but those following should be considered, (a). Loss of 
weight. The present weight, the best weight, and the weight prior to 
any noticeable impairment of health should be ascertained, as few cases 
develop without progressive weight loss.* (b). Indigestion. Dyspeptic 
symptoms are common in the early stages of tuberculosis, and loss of 
weight is often -attributed to that cause when it should be traced further 
back. (c). Cough. This may be entirely absent and is frequently 
unnoticed and denied by the patient, even though audible to the examin- 
ing physician. It is often harassing and troublesome, particularly in 
the advanced stage of the disease, and may be entirely unproductive, 
hardly more than a clearing of the throat, or, associated with profuse 
expectoration or even haemoptysis being oftentimes bronchiectatic in 
advanced cases, (d). Sputum. The sputum may be absent, mucoid, 
muco-purulent or purulent, according to the stage of the disease. Tuber- 
cle bacilli are present in all advanced cases, but a diagnosis must often 
be made in their absence. When found by proper staining methods the 
evidence is positive and final, (e). Pain may or may not be present, 
and is often represented by a feeling of mere oppression, at other 
times being distinctly pleuritic in type or dull and ill-defined, (f). 
Ancemia is frequently present in the early stages of the disease, and 

* Robust appearing heavy weights may have lost thirty or forty pounds 
and such patients often receive scant sympathy and no proper examination. 



TUBERCULOSIS. 



157 



always in advanced cases. In the former it is sometimes of the chlor- 
otic type, but usually one finds a secondar y anaemia (see pp.397, 402). 
(g). Dyspnoea. Dyspnoea on exertion is not uncommon early and is 
an invariable late symptom, (h). Bronchitis. A diffuse obscurant 
bronchitis or often spasmodic asthma is sometimes present and may 
mask the true lesion. In other instances it is a localized and suggestive 
bronchitis, (i). Pleuro-pericardial friction. The author has come 
to regard with great suspicion frictional murmurs, pleuro-pericardial 
in type and site, not associated with a definite attack of pericarditis or 
pleurisy, but with impairment of the general health. In several instances 
these have proven the first demonstrable symptoms of a rapidly des- 
tructive tuberculous process, (j). Night sweats. This troublesome 
symptom is ordinarily associated with the final stage, but may be 
encountered at any time in the course of the disease. Such sweats 
are chilling and exhausting, (k). Pulse. In connection with other 
symptoms the excitability and undue rapidity of the pulse is extremely 
important. (1). Temperature. In advanced tuberculosis, the temper- 
ature is simply that of a septic process, being distinctly intermittent or 
hectic in type and associated with night sweats. When new areas 
of the lung tissue are invaded, the temperature is likely to be continuous, 
or only remittent. One is chiefly interested in the variations in incipient 
cases and here one must emphasize the importance of any persistent 
rise above the normal. In all tuberculosis cases with fever, the maxi- 
mum rise is usually in the evening, but we may have an inverse temper- 
ature with the evening normal. Some cases have no temperature, and 
one under the author's observation a few years ago, went through the 
various stages of the disease to death without a rise above 99 F* In 
many cases a temperature will be found only after exertion, and this is 
a matter of the greatest importance in relation to both diagnosis and 
treatment. Furthermore, in such cases a wide variation between the 
morning and evening temperature, though the latter be within normal 
limits, may be as serious an indication as the abnormal rise. (mV 
Fluoroscopy. The skilful use of the fluoroscope throws much light 
upon the condition of the lungs in incipient cases and one often finds 
a marked limitation of lung movement, as measured by the descent 
of the diaphragm, quite disproportionate to the amount of lung involved, 
Areas of extensive infiltration show as shadows, and cavities of consider- 



Often con- 
fusing. 



Suggestive 
types. 



May be 
early. 



Sugges- 
tive. 



All 
important. 



Afebrile 
cases. 



Exertion 
tempera- 
ture. 



Valuable. 



* The case was nol observed in its incipiency, but as no temperature was 

shown duiing the Stage of softening and when the sputum was filled with 
tubercle bacilli, it is to be presumed that it was absent in the earlier stages. 



T?8 



MEDICAL DIAGNOSIS. 



able size as bright spots. Litten's sign may be used to test the dia- 
phragmatic movement in the absence of the fluoroscope. (n). Tuber- 
culin. The use of tuberculin as a diagnostic agent has its advocates 







Routine 
use unwise. 



Fig. S3- — Small yet normal heart in a case of apex tuberculosis. A form of heart 
frequently encountered in those chests of the phthisical type. 

and its bitter opponents. It is argued that inasmuch as the symptoms 
produced are due to the production of congestion in tuberculous areas, 
every dose subjects the patient to unnecessary risks. On the other 
hand its advocates claim that the importance of absolute diagnosis 



TUBERCULOSIS. 



159 



and the rarity of bad results following its use serve as its justification, 
and both are doubtless right. The author believes that its routine 
use is to be condemned. On the other hand cases occasionally arise 
where the slight risk involved may be taken in the interest of correct 
diagnosis. The fact that it is capable of producing a rise of temper- 
ature in apparently healthy controls and in certain cases of syphilis Fallible 
makes its findings less positive than might be wished, (o). Family 
history. The family history, as throwing light upon latent infection, 
predisposition, or the resistance of the patient, should be carefully 
investigated as regards both incidence and course of cases in brothers 
and sisters, parents and collaterals. 

Physical Signs. — A diagnosis must often be made in the absence oj 
positive physical signs, a fact readily appreciated if one considers the 
genesis of the disease. 

Inspection. — The physiognomy of advanced tuberculosis is too well 
known to need a description, the laity recognizing it as readily as the 
physician. It is merely a composite of emaciation, hectic, exertion 
dyspnoea, and often, of chest conformation. Incipient cases have 
no distinctive physiognomy and marked anaemia may or may not be 
present. The chest may show congenital malformation, and unilateral 
wasting of muscle in the suprascapular region is of much importance. 
The impairment of chest movement may be imperceptible in the incipient 
stage, though reduced expansion may be shown by the diaphragm 
phenomenon or the fiuoroscope. Some cases present a high color 
similar to that noted in the mitral disease of young persons and due, 
apparently, to interference with the pulmonary circulation. Advanced 
cases show marked impairment of chest movement, and oftentimes 
localized contraction, abnormal pulsation along the pulmonary-cardiac 
boundaries, and, the characteristic phthisical chest. 

Palpation. — Palpation may be wholly negative in the incipient stage, 
though yielding most exquisite signs in the advanced cases where it 
reveals lack of expansion, inequality of voice transmission, signs of 
cavity or marked infiltration (see consolidation p. 142 and cavities 
p. 90). 

Percussion. — In the earliest stages percussion may be negative or 
actually misleading. Any inequality in the percussion notes of the 
two sides, particularly at the apex, should attract attention. It should 
be remembered that, normally, the note on the left side is less intense 
but more resonant and lower pitched than that of the right. Hyper 
resonance at the apex, if unilateral, is a valuable sign oi an incipient 



1 mpor- 

tance 

variable. 



Often 
negative. 



Important 
data. 



i6o 



MEDICAL DIAGNOSIS. 



Hyper- 
resonance. 



Unilateral 
variation. 



Cog-wheel 
breathing. 



Cough 
manoeuvre. 



Know the 
normal. 



Apex signs. 



Line of 
march. 



Posterior 

vs. 
Anterior. 



X-Ray. 



process; in the later stage it is of course likely to indicate vicarious 
emphysema or the presence of cavities. Patches of dulness may be 
made out, or extensive areas of infiltration, with or without cavity form- 
ation, according to the status of the case. 

Auscultation. — This is by far the most important procedure. Uni- 
lateral diminution of the breath sounds or of voice conduction may be 
as significant as an increase in their intensity. Harsh breathing and 
the so-called cog-wheel inspiration must be carefully noted and the 
latter must not be confounded with the inspiration associated with an 
over-acting heart, such a condition being frequently met with in tuber- 
culous subjects. Undue prolongation of expiration, though it be low 
pitched, may be a sign of importance and in advanced cases with marked 
infiltration and cavity formation the breath sounds are frank and 
characteristic (see page 101). Rales may be absent for a considerable 
period in the incipient stage. One often hears only fine sibilant sounds, 
most significant if detected at the apex even in the absence of other 
signs, and particularly so if unilateral. Every patient should be made 
to cough in order to bring out rales, and deep inspiration following 
cough may be attended by sibilant, crackling or bubbling rales or by 
the so-called mucous click, according to the stage of the disease. In 
advanced cases the rales are of all types as described on page 104. 

Comment. — Certain points are absolutely essential to the proper 
examination and early diagnosis of tuberculous cases. A knowledge 
of the sounds produced by the various manoeuvres in the normal chest 
is absolutely necessary. Unilateral variations are infinitely more impor- 
tant than bilateral ones in the incipient or early cases. Inasmuch as 
the disease usually commences at the apex or apices, this region is the 
most important for the diagnostician. (Both are affected almost 
coincidently far more often than is generally supposed.) The primary- 
lesion is commonly slightly posterior to the centre and about an inch 
or an inch and a half below the apex. The disease tends to extend 
both upward and downward along the interlobar fissure and in front 
along the inner margin of the upper lobe. Posterior apical auscultation 
is usually more productive than anterior in the early stages of the disease. 
The important areas are the apex, anteriorly and posteriorly, the inner 
lung borders anteriorly, the apex of the axillary space, and, the region of 
the interlobar fissure posteriorly as roughly indicated by the scapular 
border when the arm is placed upon the opposite shoulder. The lungs 
may often be more involved than physical signs would indicate, as any 
one may prove bv the use of the X-Ray and this fact no doubt accounts 



PULMONARY ABSCESS. 



161 



for the errors in prognosis and failure in treatment in cases judged wholly 
by the physical signs. 

Apex Movement. — It is important to employ auscultatory per- 
cussion over the apices in order to determine the height at which 
they stand and the difference in level as between inspiration and 
expiration. Marked retraction of one apex is an important sign of 
either an old lesion, or an active and advancing one. The diaphragm 
phenomenon has already been described (p. 88). 

PULMONARY INFARCT (pulmonary apoplexy, hemorrhagic in- 
farct, pulmonary embolism). — All emboli in the pulmonary artery originate 
in the right heart or in thrombotic systemic veins, and may be septic or 
nonseptic. The former occur in pyemia, ulcerative endocarditis, septi- 
caemia and exceptionally severe acute febrile infections; the latter result 
from the detachment of vegetations from the tricuspid or pulmonary 
valves or from a remote non-septic thrombus. The result is usually 
the blocking of a branch of the pulmonary artery which causes a local- 
ized pneumonia primarily representing the distribution of the affected 
vessel and in some instances leading to abscess or gangrene. The 
area is usually wedge shaped with its base at the periphery. 

Symptoms. — Tiny infarcts may be wholly symptomless or produce 
only slight cough, dyspnoea, and perhaps hemoptysis. If branches of 
moderate size be involved these symptoms are more pronounced or indeed 
extreme and if a large artery be affected instant death restdts. The sudden 
onset of such symptoms accompanied by the physical signs of circum- 
scribed pneumonia or pleuro -pneumonia, usually basal, in the presence 
of recognized causative factors makes the diagnosis easy. If the embolus 
be septic the case becomes one of pulmonary abscess or gangrene. If the 
septic element be absent prognosis is favorable as regards the lung 
condition. In septic cases it is bad. Multiple infarcts may occur and 
their location be easily determined as in a case recently observed; and 
the picture presented, viz, sudden localized pain, dyspnoea and bloody 
sputum is characteristic even though the physical signs be obscure. 

PULMONARY ABSCESS.— The abscesses may be single or multi- 
ple and due to tuberculosis, septicemia, pyemia, septic emboli, lobar and 
broncho-pneumonia, malignant endocarditis and indeed to suppur- 
ative disease of any organ or structure adjacent or remote. There is 
usually an associated empyema with embolic infarction abscesses 
which are often multiple. Other abscesses may be distinctly locali sed 
primarily but tend to extend. 

Symptoms. — The symptoms are those of sepsis (see septicemia and 
ii 



Height 
important. 



Associated 
ailments. 



Peculiar 
area. 



Diagnosis 
easy, or, 
impossible. 



Multiple 
lesions. 



Often 



. 



162 



MEDICAL DIAGNOSIS. 



Perfor 
ation. 



Sputum. 



Rare. 



Power lobe 
chiefly. 



Perfor- 
ation. 



pyemia) and the physical signs may be vague or lacking if central, 
or simulate an encysted empyema if superficial, unless perfor- 
ation occurs (most commonly into a bronchus) and is associated 
with the sudden appearance of a considerable quantity of purulent 
sputum which then persists with distinct cavity signs. The sputum 
is foul, contains elastic tissue and often at first or at intervals more 
or less blood. It will be noted that the symptoms of sepsis apply to 
all forms; but non-perforating abscess may yield no symptoms or only 
percussion dulness and, compression. 

Prognosis. — Embolic abscess is almost invariably fatal and the prog- 
nosis is bad in all though their course may be prolonged or recovery 
achieved, usually through surgical interference. 

PULMONARY GANGRENE.— The etiologic factors are chiefly those 
of pulmonary abscess. It is a rare complication of diabetes and pneumonia , 
exceptionally rare in tuberculosis and varies greatly in extent, being 
either circumscribed or diffuse and usually but not always affecting 
the lower lobe. The involved areas are surrounded by consolidated, 
congested or edematous areas. An associated empyema is common and 
pleurisy invariable in the peripheral lesions. It shows the same tendency 
to perforate as does abscess, most commonly into a bronchus, more 
rarely into the pleura or even the pericardium, esophagus, or, through 
the diaphragm. 

Symptoms. — The only symptom differentiating the disease from pul- 
monary abscess is the peculiarly horrible odor of the sputum, character- 
Odor diag- istically gangrenous and simulated by no other condition except pul- 
monary carcinoma with gangrene. Owing to some peculiar fermen- 
tative action the sputum contains no elastic tissue. 

Prognosis. —Embolic malignant and diabetic cases invariably die; 
in others the prognosis is unfavorable but not absolutely hopeless. 

PULMONARY TUMORS.— Only the malignant variety need be 
considered. Primary sarcoma is a clinical curiosity and carcinoma rare, 
both being usually metastatic. The most common primary focus is of 
course the mammary gland, less often uterine, gastric, rectal and osse- 
ous growths. Pulmonary carcinoma is most common in middle age. 

Symptoms. — The disease is often strikingly symptomless for long 
periods or baffling and indeterminate, the size and location of the 
growth being the chief factor; obstinate and violent cough may or may 
not be present. Sputum may be entirely absent or like prune juice or 
currant jelly, blood streaked or even purulent and of gangrenous odor, 
and contains compound granule cells. Involvement of the pleura may 



Primary 
rare. 



Frank or 
obscure. 



DISEASES OF THE BRONCHIAL GLANDS. 



163 



produce severe pain and the dyspnoea usually present in some degree 
may be strikingly paroxysmal; pressure symptoms may be marked 
and are often identical with those of aneurism (see page 205). Fever 
is often noted as the disease advances, profuse hemorrhage occasionally 
occurs and there may be marked displacement of the heart. Secondary 
growths are usually suggested by a primary lesion, but primary ones are 
frequently beyond a positive diagnosis. The X-Ray may prove valuable 
in such cases and if the growth be accessible and of considerable size it 
may yield percussion dulness, usually without tubular breathing, and 
increased fremitus, more rarely, if attached to a large bronchus, both 
phenomena. 

Prognosis. — Death invariably results though only after a period of 
several months.* 

DISEASES OF THE BRONCHIAL GLANDS— The most im- 
portant of these glands lie in the angle of the tracheal bifurca- 
tion about the main bronchi. The smaller glands follow the course 
of the bronchi lying in the interlobular connective tissue. They 
must chiefly be considered in connection with the ailments of 
children or adults, as possible sources of secondary enlargement with 
or without symptoms. It should also be remembered that gangrene 
of the lung may involve them and that through dusty occupation, (in- 
halation of dust) they may become pigmented and somewhat enlarged. 
The following diseases may affect them: — (a). Severe acute bronchitis, 
(b). Scarlet fever, measles, whooping cough, typhoid and similar 
ailments, (c). Broncho and lobar pneumonia, (d) Pulmonary gan- 
grene, (e). Mediastinal, or, by metastasis, remote, malignant growths, 
(f). Hodgkin's disease and leukaemia (especially the lymphatic form), 
(g). Pulmonary tuberculosis, (h). Tuberculous or malignant disease 
of the abdominal or retro- peritoneal structures. The greater number of 
cases in children are due to tuberculosis, the primary source of infection 
being either gastro-intestinal, tonsillar or bronchial. 

Symptoms. — Manv enlargements are symptomless, in other cases 
the effects are those of pressure within the mediastinum combined 
with physical signs chiefly observable in the interscapular region and 



Pressure 

symptoms. 



X-Ray. 



Important 
areas. 



Age. 



Occupa- 
tion. 



Associated 
lesions. 



Tubercu- 
losis. 



Pressure. 



* In the only case of primary sarcoma of the lung observed by the author 
no positive diagnosis could be made during life, though the ailment was 
suspected by reason of the peculiar shadows shown by the X-Ray. The 
physical signs were indeterminate, the heart signs and pressure symptoms 
slight but somewhat suggestive of aneurism and the autopsy showed small 
disseminated growths, bilateral in distribution though chiefly affecting the 
left lung. 



< 



164 



MEDICAL DIAGNOSIS. 



Seek a 
cause. 



Rare and 
obscure. 



Fibrosis. 



Types 



upper sternum. These signs are usually so indefinite, occurring as 
they do in areas most unfavorable for percussion or auscultation, that 
the early diagnosis rests usually upon pressure symptoms and the knowl- 
edge of an adequate cause. (The subject of pressure symptoms is 
thoroughly discussed under the head of aneurism, page 205.) They 
are practically identical in all forms of mediastinal growth, though the 
most distressing cases ever observed by the author have been associated 
with the glandular enlargement of Hodgkin's disease. 

MEDIASTINAL ABSCESS.— This excessively rare condition may 
be acute or chronic, and occurs chiefly in the male in connection with 
traumatism, the acute infectious diseases, pulmonary abscess, gangrene 
or advanced tuberculosis. It is recognized by the symptoms of sepsis 
associated with severe substernal pain and marked pressure symptoms. 
It may rupture and produce a fluctuating tumor in an intercostal space 
or discharge into the esophagus or trachea. The use of a fine aspirating 
needle usually makes the diagnosis. 

CHRONIC INTERSTITIAL PNEUMONIA (fibroid phthisis, 
pulmonary cirrhosis). — In spite of years of observation the conditions 
characterized by extensive fibroid changes remain imperfectly classified. 
In a broad sense it is best treated under the one heading and we may 
assume that lobar pneumonia, broncho-pneumonia, old pleurisies, 
syphilis, echinococcus cysts and tuberculosis may operate to produce 
a lesion, the chief characteristic of which is fibrosis. Chronic diffuse 
interstitial pneumonia is excessively rare as a sequence of acute lobar 
pneumonia though a few cases have been described with some accuracy. 
Chronic broncho-pneumonia is more common but is usually tubercu- 
lous. An interstitial pneumonia following pleurisy (pleurogenous) 
undoubtedly occurs as a result of prolonged compression, it being asso- 
ciated usually with a greatly thickened and adherent pleura. The 
cases of interstitial pneumonia due to continuous dusty occupations 
(pneumonokoniosis) and the syphilitic tuberculous and echinococcus 
forms are better understood. 

Morbid Anatomy .—The process may be lobar (massive) or lobu- 
lar (peribronchial, broncho-pneumonic, insular). The sound lung is 
markedly emphysematous and the heart is thus pushed and drawn 
towards the diseased lung, pulmonary shrinkage and adhesions being 
usually marked, though sometimes lacking (e.g. in pneumonokoniosis). 
The lung itself may be marvelously shrunken and show chronic bron- 
chitis, multiple bronchiectases and perhaps aneurismal dilatations of 
the pulmonary artery. The heart is enlarged, its right chambers being 



Compensa- 
tory emphy- 
sema. 

Retraction 



PULMONARY SYPHILIS. 



i6< 



especially dilated. The varied nature of the lesion makes possible 
wide differences in post mortem findings. The most extreme cases 
represent the massive form of the disease, while gummata, apical 
tuberculous cavities or echinococcus cysts may indicate the specific 
primary cause as may the peculiar pigmentation of the tissue 
observed in cases of anthracosis (coal miner's disease) and siderosis 
(due to metallic particles), chalicosis (grinder's rot, stone cutter's 
phthisis). 

Symptoms. — The symptoms accurately follow the morbid anatomy 
as stated, being those of emphysema, chronic bronchitis, bronchiectasis 
or chronic phthisis, according to the nature and extent of the lesions, 
combined with physical signs bearing the same relation to causation. 
The displacement of the heart, retraction and immobility of the affected 
side, scoliosis, and the depressed shoulder are emphasized by com- 
parison with the voluminous opposite side. Symptoms of marked 
infiltration are usually found but vary widely with the degree of involve- 
ment. The disease is not only remarkably chronic but one which 
permits considerable activity for many years or even for a reasonably 
long lifetime* 

PULMONARY SYPHILIS.— There are no characteristic symp- 
toms of this disease which most commonly manifests itself as inter- 
stitial pneumonia. It occurs both in congenital and tertiary acquired 
syphilis. The so-called white pneumonia is of no clinical importance, 
being found only in the lungs of dead babes usually stillborn. The 
former process is frequently associated with tuberculosis. In acquired 
syphilis, gummata, single or multiple, varying in size from a small seed 
to a hen's egg may be encountered. The physical signs are in no way 
peculiar to syphilis. Whether there is an actual destructive dis- 
ease of the lung and true syphilitic phthisis is still debatable. There 
are certainly rare cases in which softening is associated with caseous 
gummata and similar cases not infrequently occur in connection with 
tuberculosis.f 

* One case observed by the author during a period of nearly 20 years has 
passed through several severe illnesses ami has lived to see his two healthy 
brothers die of acute disease; another case, showing the classical signs oi 
inherited syphilis and every evidence of massive chronic fibrosis, has under- 
gone an appendicectomy and nephrotomy ami several attacks oi influenza. 
Both men have been almost continuously at work during the whole 
period. 

t No one can have failed to encounter cases oi undoubted acquired syphilis 

in which a rapidly advancing tuberculous process showed a marked im- 
provement following the use oi specific medication. 



Cardiac 

changes. 



Anthra- 
cosis. 



Siderosis. 



Usually 
marked. 



White 
pneumonia. 



Tubercu- 
losis and 
syphilis. 



J 



i66 



MEDICAL DIAGNOSIS. 



Differen- 
tial factors. 



Resembles 
tuberculo- 



PULMONARY ACTINOMYCOSIS.— In all essential particulars 
this disease presents the picture of pulmonary tuberculosis and its 
diagnosis almost invariably depends upon the recovery of the specific 
organism from the sputum. It should be suspected if in such cases 
tubercle bacilli are absent, the bases chiefly or primarily involved and 
superficial swellings or brawny inflammations noted. 

ASPERGILLOMYCOSIS — This rare disease is due to the asper- 
gillus fumigatus and has been observed chiefly in those who handle 
infected flour, meal or grain. The symptoms are essentially those of 
pulmonary tuberculosis without the bacilli and the diagnosis can be 
made only by the discovery of the mycelium. It may also occur as a 
secondary disease in connection with the various chronic pulmonary 
ailments and may assume a predominatingly bronchial, nodular, or, 
cavernous form. 

PULMONARY HYDATIDS.— Diagnosis.— So long as hydatid 
cysts are central and small, few or no symptoms are produced. If they 
enlarge, and particularly if they reach the pleura, cough and pain may 
be severe. Fever is usually absent, and dyspnoea slight. Physical 
signs may be baffling, indeterminate, or, those of consolidation or 
pleuritic effusion with the usual pressure displacements but weakened 
breath sounds and diminished fremitus. The area of dulness may be 
characteristically circular or with signs of effusion there may be marked 
pleural friction over the area of dulness as in Dr. Bristowe's case.* If 
rupture occurs the immediate symptoms may be urgent, the watery 
nature of the fluid is suggestive and characteristic and hooklets and 
fragments of the membrane may be present. Hydatid thrill and 
superficial rounded tumors may be found. Fowler emphasizes the rel- 
ative absence of mediastinal pressure symptoms (see aneurism) despite 
the evidences of a large tumor or exudate. 

CHYLOUS PLEURISY.— A chylothorax results usually from oc- 
clusion or rupture of the thoracic duct or receptaculum chyli, usually 
as a result of malignant or tuberculous disease. The diagnosis can 
only be made by the discovery of a pleural effusion and the removal of 
a portion for examination. Such cases lack any history of acute 
pleurisy. 

MALIGNANT GROWTHS OF THE PLEURA.— What is said 
under the head of malignant growths of the lung applies here save that 
the primary signs and symptoms are pleural. Not only is pleural effu- 
sion simulated but in many instances actually present. Cardiac dis- 

* Referred to by Fowler. 



Symptoms 
variable. 



Peculiar 
cases. 



Rupture. 



Explora- 
tory punc- 
ture. 



Effusion. 



THE HEART AND BLOOD VESSELS. 



167 



placement is usually less marked than in simple effusions but usually 
a differential diagnosis depends upon the withdrawal of blood stained 
fluid in amount disproportionate to, or without a proper diminution of, 
the area of flatness. 

THE HEART AND BLOOD VESSELS. 

THE ARTERIAL PULSE.— Whenever possible the pulse should 
be taken casually while talking of other matters and allowance made 
for the nervousness incident to examination and the effect of physical 
exertion. 

Technique. — A correct technique is of the utmost importance and 
the patient's arms should be similarly placed in a position free from re- 
straint, flexion, or muscular compression of the vessels. The pulse 
should be taken simultaneously in the two radials and three fingers ap- 
plied lightly over the artery at the wrist.* 

Points to be Determined. — (1). The size of the artery. (2). Pulse 
rate or frequency . (3). Regularity of rhythm. (4). Uniformity of 
strength. (5). Synchronism and equality of the right and left radial 
pulses. (6). The force required to obliterate them (tension.) (7). Ab- 
normal thickening of the artery (arterio-sclerosis). 

When the physician's fingers are applied to the artery the first four 
points are determined almost unconsciously and instantaneously, the 
vessel being lightly rolled under the finger to get its size, and pressure 
made with the upper finger until the pulse is lost to the lower, the force 
exerted being the measure of tension. The empty artery is then rolled 
under the lower finger to detect any thickening of its walls (arterio- 
sclerosis) and any vessel that can thus be felt as a distinct tube is scler- 
otic and hence abnormal. Such may be merely palpable, distinctly rigid. 
or, carry tiny plaques of lime salts. 

Precautions. — It is ordinarily sufficient to count the pulse for 15 
seconds and multiply by 4 to get the rate per minute, but if any abnor- 
malities in rhythm, quality or force be present, it should be taken for at 
least one minute and if excessively rapid it may be necessary to count 
every second or third beat. Not infrequently, especially in certain 
valvular lesions, some systoles are inefficient, ami, though readily auscul- 
tated, yield no pulse wave and in such cases nurses' pulse records are 
frequently worthless. A recurrent pulse is one (hat cannot be cut otT by 
the pressure of the upper finger because of an unusually free coinnum 

*There is no better proof of bad training than the gingerly one-fingered 
approach sometimes observed. 



Caution. 



Important 
factors. 



Size and 

tension. 



Special ma- 
ncevn 



Vitiated 
records. 



1 



i68 



MEDICAL DIAGNOSIS. 



How 
detected. 



Position of 
arm. 



Weak 
pulse. 



Misleading 
variations. 



A common 
error. 



Exertion 
and atti- 
tude. 



Age. 



Sex. 



Fever. 



Pulse tem- 
perature 
ratio. 



ication and recurrent flow from the palmar arch. This may be obviated 
by making obliterating pressure with the lower ringer and carrying out 
the usual procedure above, or, by compressing the ulnar artery. Faulty 
position of the patient's arm and hand may greatly modify any pulse. 
The forearm should be slightly flexed upon the elbow, the wrist thrown 
slightly backward, and very slightly supinated. A careless student 
frequently fails to note unequal force in succeeding beats or jumps at 
conclusions if he finds a unilateral weakening or absence of the pulse. 
The former is most important evidence of deficient heart strength, 
the latter is ordinarily due to an abnormal course of the radial artery, 
or more rarely, to actual blocking of the vessel or to aneurism, and the 
findings must always be checked by comparing the larger arteries, such 
as the brachials of the two sides. A full bounding pulse is frequently 
mistaken for a high tension pulse because of faulty technique. The 
correct determination requires much practice and for extreme accuracy 
demands the use of the special instruments. 

Pulse Frequency. — Aside from mental excitement, the digestive 
process and bodily exertion, which latter includes even the slight disturb- 
ance due to readjustment of the position in bed or evacuation of the blad- 
der or bowels, the position of the body affects the findings and in erect 
posture the rate is from 10-15 beats faster than when recumbent. The 
sitting posture shows a rate midway between the two.* The average 
normal rates are for the first year of life from 130-140; from the first to 
the fourth year gradually dropping to 105 or no; and so diminishing 
until at the fifteenth or sixteenth year it reaches from 75 to 80 beats 
per minute. During middle age and up to 60 years frequency is slightly 
diminished, sometimes increasing somewhat beyond that age. Women 
show a rate from 5-8 beats a minute faster than men, and it is slightly 
slower in tall than in short persons. Fever. Any abnormal increase 
in frequency suggests the use of the clinical thermometer and we find 
that as a rule the rate increases from 8-10 beats per minute for each degree 
of temperature above the normal, and further, that the behavior of pulse 
J in fever is of both diagnostic and prognostic importance. f In general 
J an increase in the rate out of correspondence with the rule given suggests 
diminished resistance to the disease and constitutes a danger signal. 
In those few diseases in which the pulse rate should be lower than the 

* This variation was formerly believed to be due to pulse tension as 
affected by posture, a theory exploded by the fact that the sphygmograph 
shows but a trifling variation in pressure. 

t See Fever, p. 49. 



THE HEART AND BLOOD VESSELS — PULSE. 



169 



Diseases 
suggested. 



Rapid 

pulse. 



rule, excessive rapidity has a still greater significance. High temperature 
and relatively slow pulse are observed especially in tubercular meningitis, 
typhoid fever, yellow fever and lobar pneumonia, as well as in febrile 
ailments associated with some of the organic causes of slow heart, such 
as coronary sclerosis, myocarditis and aortic stenosis. In feverish 
children a relatively rapid rate is of far less significance than in the adult. 
A rapid pulse occurs in many non-febrile ailments, most markedly in 
exophthalmic goitre and in the slight or marked incompensation stages 
of mitral stenosis and insufficiency, myocarditis and aortic insufficiency, 
and in acute endocarditis, pericarditis, and, the pressure displacements 
of the heart. In children an excessively rapid pulse may suggest 
the onset of scarlatina before the appearance of the rash and in incipient 
pulmonary tuberculosis, an excitable and persistently over-rapid pulse 
is one of the most constant and significant of the early signs. Aside from 
these organic disturbances must be considered sexual neurasthenia, 
the overuse of tobacco (often associated with palpitation), physical 
and mental overstrain and idiosyncrasy. 

Tachycardia. — Mere excessive rapidity, paroxysmal or persistent, is 
known as tachycardia, and this term should be strictly limited to the 
pulse free from irregularity, intermittency or abnormal accentuation 
of the heart sounds. An excessively rapid "running" pulse associated 
with marked evidence of cardiac weakness and suggestive lack of 
accentuation is a forerunner of death in certain diseases. 

Bradycardia (brachycardia). — -A very slow pulse may be physio- 
logic but most of those thus described have subsequently been proven 
to be due to organic disease of the heart or brain. Excessively low 
count (20 beats to the minute) may be associated with coronary sclerosis, 
fatty infiltration and injuries. Lesser degrees of slowing may be met 
with in aortic stenosis, chronic myocarditis, cerebral hemorrhage or 
tumor, meningitis, epilepsy, general paralysis of the insane, melancholia, 
mania, myxcedema, jaundice, urasmia, exhausting disease and some- 
times, acute ailments, especially diphtheria, in which no doubt myocar- 
ditis is really chiefly accountable. In the so-called Stokes-Adams 
syndrome a bradycardia is associated with epileptiform, syncopal, or 
apoplectiform attacks. As regards its occurrence in acute infections. 
during cither the active stage or convalescence, the rule may be laid 
down that any sudden and decided drop below the normal or usual rate 
unless associated with crisis is quite as much, if not more suggestive oj Impor 
danger and of need of special watchfulness and care as would be exces- 
sive rapidity. 



Usually 
indicates 

disease. 



inference. 



. 



170 



MEDICAL DIAGNOSIS. 



Scope of 
terms. 



Signifi- 
cance. 



Varieties. 



Inequality. 



Important 
data. 



Irregularity and Intermittency. — Irregularity includes variation 
in volume and strength as well as wave intervals, though the former 
are better described by the term unequal; by intermittency is meant the 
omission of beats and the two conditions are often confounded by nurses 
and students. The stethoscope shows that intermit- 
tency may be due either to inefficient or absent systole. 
Both conditions may be temporary and trivial and due 
to purely functional disturbance or the temporary ac- 
tion of such substances as tobacco, tea and coffee. In 
the absence of definite clinical findings their signifi- 
cance is far more serious in middle aged, or elderly people than in the 



Fig. 54. 
Marked irregu- 
larity. Low- 
tension. 



Irregularity 



hKp 



Fig. 55- 
Bigeminal pulse. 



young and both variations admit of subdivisions. 
frequently combined with inequality and excessive fre- 
quency (delirium cordis) and may be transient, variable, 
persistent or periodic. A strong beat may alternate 
with a feeble one (pulsus alternans) or double or triple 
beats may occur (pulsus bigeminus, pulsus trigeminus), 
or, the normal variation due to deep inspiration may be so exaggerated 
as to make the radial pulse weak or imperceptible during inspiration 
(pulsus paradoxus). 

Idiosyncrasy is a possible factor and the greatest stress should be laid 
upon the age of the individual and the persistence of arrhythmia as com- 
pared with transient disturbance. 

Inference from Arrhythmia. — The following possible conditions 
must be considered in every case. (1). Failure of compensation in heart 
lesions whether due to arterio-sclerosis, myocarditis, fatty degeneration 
j or overgrowth, acute dilatation or valvular disease. (2). Certain stages 
i of intracranial disease or disturbances such as mental overwork and 
strain, cerebral meningitis, tumor, abscess, softening and hemorrhage 
or actual cranial injury. (3). Sexual excess and the overuse of alcohol, 
lea, coffee and tobacco. (4). The toxines of diseases such as pneumonia, 
scarlatina, diphtheria and typhoid. (5). The over-action of drugs 
such as aconite, belladonna, digitalis, cocaine and morphine. (6). 
Renal disease, exophthalmic goitre, the terminal stages of exhausting 
ailments or early stages of tuberculosis in which however rapidity and 
an easily excitable heart are chiefly observed. (7). Digestive dis- 
turbances especially those attended by flatulence. 

The paradoxic pulse is most frequently observed in excessive cardiac 
weakness, especially if associated with obstructive pressure such as may 
be exerted by pericardial effusion, mediastinal tumor (whether aneuris- 



THE HEART AND BLOOD VESSELS — PULSE. 



I 7 I 



Fig. 56. 
Aneurism. 



mal, glandular or malignant), indurative mediastinitis or laryngeal, 
tracheal or bronchial stenosis.* 

Pulsus Celer and Pulsus Tardus. — The finger, and better still the 
sphygmograph differentiates a wave or quick rise and descent (pulsus 
celer) from that of slow rise and fall. The former 
is exemplified by the water hammer pulse of aortic 
insufficiency, the latter (pulsus tardus) by the high 
tension pulse of arterio -sclerosis, interstitial nephritis, 
angina pectoris or aortic stenosis. Exact equality in the 
time of rise and fall is sometimes noted in thoracic aneurism and Sahli 
rightly affirms that even the finger may distinguish between the pulse 
that is celer in its ascent and tardus in its descent as in lesser grades of 
arterio-sclerosis. 

Full Pulse. — The artery is full between beats and may be large or 
small and of high or low tension. 

Large Pulse. — The excursion of the artery is marked as seen in 
aortic regurgitation (pulsus magnus et celer). It may be full as in 
fever {bounding pulse) but is usually of low tension. Pulsus vacuus. 
This is typified by the unsustained quality of the water hammer 
pulse, less so in mitral stenosis and extreme malnutrition, severe anaemias 
and neurasthenia. The Small Pulse. Aortic and mitral stenosis, my- 
ocarditis and aneurism furnish the best examples. The thready or 
running pulse. This small empty rapid pulse is a forerunner of death 
in most instances. Wiry pulse. This small hard pulse is best marked 
in peritonitis. 

Unilaterally Weakened or Absent Pulse. — Unilateral retarda- 
tion, weakness, or extinction, points to pressure, aneurism, throm- 
bosis, embolism, wounds, or abnormal arterial distribution. In 
aneurism of the ascending portion of the arch involving the innom- 
inate, the right radial and carotid are affected, in aneurism oj the 
descending aorta the left radial; or, a delayed pulse may accompany 
aneurism of the transverse portion. f Too much reliance should not be 
placed upon this sign oj aneurism as it is often lacking or without exact 
significance. Loss of the pulse at the ankle may be associated with in- 
intermittent claudication or be a precursor of senile gangrene. 

Dicrotic Pulse. — A second beat or echo may be felt more or less 

*The essential primary inference in any case is a weak peripheral circu- 
lation. 

t Direct sac pressure, abnormally constricted or deformed openings, or. the 
complete or partial conversion oi" intermittent into continuous Bow by the 

aneurismal sac make many variations possible. 



Disease as- 
sociations. 



Important 
inferences. 



< 



172 



MEDICAL DIAGNOSIS. 



Exhai 
tion. 



Important 
and sug- 
gestive. 



Simple 
devices. 



Janeway's 

instru- 
ment. 



Easy of ap- 
plication. 



Terms em- 
ployed. 



Fig. 57. — Dicrotism. 



distinctly under proper pressure and indicates ordinarily extreme 
exhaustion or toxaemia, early noted in typhoid fever and the typhoid 
state, but often found in exhausting diseases of various sorts, and, 
rarely, in health. The Capillary Pulse. — A large pulsus celer produces 
capillary pulsation. It is a rhythmic blushing 
and paling which may be observed over inflam- 
matory areas, in the matrix on making light 
pressure over the nails or in the forehead or chest, 
ears, etc., by reddening the skin by friction. By 
steadily pressing a glass slide or even the rim of a goblet upon the 
mucous membrane of the lips its rhythmically oscillating border is 
readily seen and it may even be observed in the retinal arteries. It 
is a valuable sign of aortic insufficiency but may also be observed in 
exophthalmic goitre, neurasthenia with anozmia, certain cases of jever, 
chlorosis, pernicious ancemia and acute hemorrhages. 

DETERMINATION OF BLOOD PRESSURE.— Fortunately for 
the clinician blood pressure may now be measured quickly and exactly by 
simple and relatively inexpensive instruments nearly all of which depend 
upon the same general principles, i.e. the translation of the pressure re- 
quired to obliterate the arterial pulse into the height of a mercury column 
in a manometer tube (see fig. 58). The portable instrument of Janeway* 
is accurate and practical because of its broad arm piece which excludes 
the errors (high readings) inherent in the narrow compression bands 
when applied to unusually fat or mus- 
cular arms, and because of its accurate 
regulation of pressure by a stopcock. 

Technique. — The hollow armlet ap- 
plied midway between shoulder and 
elbow is inflated by the hand bulb until 
the radial pulse is lost, then by the 
outlet thumb screw the pressure is 
lowered until the pulse return is just 
perceptible. As the pressure is equal in 
all parts of the closed system the height 

of the mercury column in the manometer tube is an exact index and 
the reading represents the "maximum" or "systolic" pressure. "Dias- 
tolic" or "minimum" pressure is determined by noting for ten or 

*Note. — The reader is referred to Theodore C. Janeway's admirable 
monograph for an extended discussion of this topic. " The Clinical Study 
of Blood Pressure." 




Fig. 58.— Cook's modification of 
the Riva-Rocci sphygmomanome- 
ter. 



THE HEART AND BLOOD VESSELS — PRESSURE. 



173 



twelve pulsations the increasing amplitude of the pulse wave registered 
by the mercury column as the pressure is reduced in 5 mm. series. The 
point causing maximum excursion is the index of diastolic pressure. 
Below that is a limited pressure area of equal amplitudes. The "mean" 
pressure represents the average of systolic and diastolic readings. 
Diastolic readings run about 25-40 below systolic and in low tension 

vary 50-80 and in aortic regurgitation 
up to 100 mm. A loose band or a 
rapid or excessively small pulse makes 
diastolic pressure determination impos- 
sible and in every case the arm band 
should be closely adjusted, the arm 
supported at the heart level and the 
same position taken for a series of 
tests. The limit of error in calcareous 
arteries is but 5-10 mm. and is negligi- 
ble or easily estimated. The same fig- 
ures represent the difference between 
females and <.males and the standing > 
and sitting posture. In normal pressure 
four factors are concerned, viz.: — the 
initial heart energy, peripheral resist 
ance, blood volume and the elasticity 0) 
the vessels. The normal readings according to Janeway are: — for 
young adults. 100-130; older adults, 100-145; children, 90-110; 
infants under 2 years, 75-90. Excitement may cause a rise of 40 mm. 
and concentrated physical effort a slight increase. 

Abnormally High Pressure. — In chronic interstitial nephritis the 
elements of arterio-sclerosis, high peripheral resistance and increased 
heart energy bring about high readings. In abnormal nervous excite- 
ment temporary high pressure may be observed. In secondary myocar- 
ditis with associated arterio-sclerosis, the uraemic state, lead poisoning, 
gout, cerebral hemorrhage and sometimes in parenchymatous nephritis 
or early acute nephritis high readings are present. 

Abnormally Low Pressure. — The conditions giving the lowest 
readings are shock, collapse and concealed hemorrhage. In visible hem- 
orrhage attended by nervous excitement, fear, and apprehension the 
pressure is raised. The acute injections diseases, anaemias and cach- 
exias and the terminal stages of all diseases show low pressure. 
The Sphygmograph and Sphygmogram. The sphygmograph has 




Fig. 59.— Gartner's tonometer. 



Variations. 



Sources of 
error. 



Sclerosis. 



Sex and 
attitude. 



Factors 
involved. 



Normal 
readings. 



Various 

factors. 



174 



MEDICAL DIAGNOSIS. 



Useful. 



Xot indis- 
pensable. 



Principle. 



Easy of 
applica- 



Caution. 



Elements. 



undoubted value in connection with pulse taking, yielding in certain 
directions more important information than may be derived from touch 
and making if desired a permanent record. But although its use does 
not involve much time, the relation of time lost to information gained 
makes it unlikely that it will ever be extensively used in clinical work 
outside of hospital or consultation practice. Certainly it cannot replace 
ordinary pulse taking, if for no other reason than its failure to show the 
size of a pulse, and the condition of the arterial walls. The forms of 
sphygmograph in most common use are those of Marey and Dudgeon, 
either of which gives excellent tracings. A detailed description is 
unnecessary, the principle of all sphygmographs being that of the trans- 
mission of the pulse wave to a lever so arranged as to register the excur- 
sion of the compression pad upon some substance such as smoked 
paper which is passed under the point by clock mechanism at a known 
rate per second. The difficulties attending the operation of these instru- 
ments and the effect of the 




Fig. 60. — Marey's sphygmograph. 



personal equation in interpre- 
tation have been unduly mag- 
nified ; a little practice suffices 
and the differences in results 
are not so great as to obscure 
their clinical value. To make 
permanent records special 
paper may be obtained of a 
smooth, highly calendared 

surface which is easily smoked (not scorched) over the flame of burning 
camphor or even an ordinary candle. This, after tracing the name 
of the patient and the date, is dipped into a solution of photographer's 
varnish or similar substance and dried. The instrument may be used 
with or without the wrist band but the hand must always be supported 
at heart level. Before starting the clock work the pad should be, and 
remain, exactly over the artery and the milled head turned until the 
needle shows its maximum amplitude of movement;* the hand itself, 
slightly dorsiflexed, should rest steadily palm upward, with the fingers 
slightly bent. 

Sphygmogram. — The analysis of all tracings depends upon a thorough 
understanding of that of the normal pulse. In this we recognize an 
anacrotic or ascending limb which at its summit or apex becomes the 

* It is usually best to make several tracings under slightly varying pres- 
sures. 



THE HEART AND BLOOD VESSELS — PRESSURE. 



175 




Fig. 61. 
Normal sphygmogram. 
b.c. percussion upstroke. 
b. c. d. percussion wave, 
d. e. f. tidal wave. g. 
dicrotic wave. 



katacrotic or descending limb, the latter being divided into two chief 
waves, the higher being the. tidal or predicrotic, the lower the recoil or 
dicrotic wave; between these two elevations on 
the descending limb is a hollow representing the 
aortic closure; the apex height shows the max- 
imum excursion, the two secondary elevations on 
the descending limb the reactive contractions of 
the artery. 

Normal tracings show a nearly vertical up- 
stroke of moderate amplitude, a gradual descent 
and a moderately sharp apex, the tidal wave 
being small, the dicrotic low but well marked. 
Abnormal tracings show: — (a). Broad apex. 
This indicates high tension and a strongly acting heart, aortic stenosis, 
aneurism, or too great pressure of the pad. (b). An unduly long sharp 
apex indicates low tension, and is 
especially marked in aortic regurgita- 
tion, (c). A short upstroke indicates 
Fig. 62.— Aortic small volume; as in mitral regurgita- 

regurgitation. . . 

tion, aneurism, aortic stenosis, and 

arterio-sclerosis. (d). A long upstroke means free 

peripheral circulation, sharp systole, or in general, low tension. 
Aortic regurgitation furnishes a typical 
example, (e). Excessive obliquity of the 
upstrokes points to slow filling of the 
artery and is especially noticed in mitral 
stenosis or regurgitation, arterio-sclerosis, 

aneurism or a weakened myocardium, (f). A vertical upstroke indicates 
large blood volumes and quick systole 
whether strong or weak and is exempli- 
fied by aortic regurgitation, (g). A marked 
tidal wave suggests high terfsion or actual 
obstruction as in aortic stenosis orarterio- 

sclerosis with a strong cardiac impulse, (h). A diminished tidal wave 

indicates cardiac weakness, or. strength 

with relaxed peripheral circulation, as in 

mitral or aortic regurgitation, (i). Marked 

dicrotic wave points to low tension or to high Fig. 69.— Aortic 

tension with cardiac weakness. It is host 




Fig. 63.- High 
tension. 



Fig. 64.— Undu- 
lating base line. 



Fig. 65. — Arte- 
rio-sclerosis. 



Fig. 66.— Irreg 
ularity. 



Fig. 



Anou- 



Fig. 68.-Pulsi 
biferiens. 



marked in the pulse of typhoid fever, (j). Lessened dicrotic wave. Aside 



176 



MEDICAL DIAGNOSIS. 



Undulant 
pulse. 



Systolic 
collapse. 



Positive 
systolic 
pulse. 



Hepatic 
pulsation. 



-Ar- 

terio-sclerosis. 



from aortic regurgitation this points to an obstructed circulation with 
a strong systole, i.e. aneurism, arterio -sclerosis and aortic stenosis. 
Aside from these points, irregularities in the line of descent are noted 
in mitral lesions ; irregularities of the base line cor- 
responding to respiration in dyspnoea or any form of 
irregular forcible breathing; and any inter mittency, ir- 
regularity or hemisystole is made clearly evident by the 
tracings. The plates accompanying this section clearly 
show the characteristics mentioned in the foregoing paragraph and 
it will be seen that an observer who thoroughly understands the prin- 
ciples involved can obtain information of considerable diagnostic, 
prognostic and therapeutic value. 

VENOUS PULSE. — When distinguishing between the physiologic 
negative pulse and a pathologic positive pulse the external jugular is 
the vessel usually examined as being most superficial and accessible. 
The negative pulse disappears above and diminishes below the 
finger compressing the external and internal jugular veins, or, better 
still, both these and the subclavian, and is apparently due, not to direct 
regurgitation of the blood, but the transmission of a suction wave 
from the heart to the vein. Neither is it dependent upon destruction 
of the venous valves as its direction coincides with the normal blood 
flow through them, nor transmitted from the artery, else it would persist 
peripherally. Coincident sphygmographic tracing of the carotid 
pulse and the negative venous pulse proves the latter to be diastolic. 
By the same method the systolic venous pulse, proof positive of tricuspid 
regurgitation, is shown to be a systolic regurgitant pulse. It is chiefly 
apparent in the bulb, though occasionally peripheral and in extreme 
cases, especially in children, there is coincident expansile pulsation oj 
the liver as a whole, most easily recognized by placing one hand upon the 
right lower thoracic zone, posteriorly, and the other over the enlarged 
liver in front. This manoeuvre is necessary to eliminate the spurious 
transmitted pulsation frequently observed in cardiac dilatation* The 
positive venous pulse is lost peripherally but unaffected or increased cen- 
trally by compression. 

Diastolic Venous Collapse. — This rare sign indicates extensive peri- 
cardial adhesion and is due to diastolic recession of the chest wall 
accompanied by diastolic intra-thoracic suction. In appearance it 
resembles the positive (systolic) venous pulse, but under obliterating 



Resembles 

positive 

pulse. 



* Sahli reports a case in which localized inflammatory pulsation of the 
liver occurred as the result of a suppurative cholangitis. 



EXAMINATION OF THE HEART AND GREAT VESSELS. 



177 



pressure the wave is centrally diminished or lost * Compression should 
include both internal and external jugular veins in all attempts to dif- 
ferentiate the venous pulsations. 

Positive Penetrating Venous Pulse. — Very rarely and usually in 
association with a capillary pulse a pulsation may be observed in the 
terminal venous radicles. Compression causes central obliteration 
but does not affect the peripheral portion. 

Other Visible Respiratory Venous Phenomena. — The swelling of 
the veins of the neck during violent straining or sustaining a musical 
note is familiar to everyone and is seen in all forms of severe dyspnoea, 
whether temporary or permanent. In chronic conditions the over- 
distension becomes permanent and occasionally the usual inspiratory 
diminution and expiratory fullness is reversed, in which case indurative 
mediastinitis, chronic pericarditis, pleuritis, aneurism or any other 
form of mediastinal tumor is suggested. Students often find difficulty 
in distinguishing between venous pulsation of the internal jugular 
and carotid pulsation; the former covers a wider area and is undulatory 
and deliberate in character, and pressure upon the carotid does not 
affect it. 

EXAMINATION OF THE HEART AND GREAT VESSELS. 

Inspection.- — This should be both direct and tangential, general and 
local. The most important regions are : (a). The valvular areas described 
on page 84. (b). The manubrium and its neighborhood, (c). The 
area lying between the inner edge of the left scapula and the spinal col- 
umn. One seeks chiefly to note: — (a). Abnormal pulsations, (b). 
Asymmetry, (c). Tumors. 

The Apex Beat. — This should be represented by a gentle rhythmic 
uplifting of the fifth interspace in an area not more than an inch in 
diameter, well within the mid-clavicular line. It is not always present 
in health, either because of overlying fat or an intervening rib and 
the beat is often excessive even in the case of a normal heart, because 
of temporary excitement, exertion, indigestion, narcotism, neurasthenia, 
etc. A heart that is abnormally strong by reason of hypertrophy 
causes a distinct and wide spread heaving (uplifting) impulse, ami 
the beat of a badly dilated heart is wavy, diffuse and indeterminate. 
In either case the area of pulsation is greatly increased. The Posi- 
tion of the Apex Beat. — Abnormalities of position must inevitably 

*The author has inserted this statement because of the weight of author- 
itative opinion but believes it to be subjeel to exception. 
12 



Common 
form. 



Rare form. 



Area and 
position. 



Forc< 



I li\»\ ins 

Wavy, 



r 



178 



MEDICAL DIAGNOSIS. 



Important 
in diag- 
nosis. 



Often mis- 
inter- 
preted. 



True or 
false. 



Mislead- 
ing. 



follow decided changes in the cardiac outline or actual displacement 
of the heart. 

Displacement of the Apex Beat. —Upward: (a). High position of 
diaphragm, (b). Tympanites, (c). Ascites, (d). Abdominal growths. 
(e). Pericarditis with effusion (often at nipple level). Upward and to 
left: — Effusion into right pleural sac. (a). Liquid, (b). Gaseous. 
Downward: — (a). Aortic aneurism, (b). Mediastinal tumor, (c). Se- 
nility, (d). Hypertrophy of left ventricle, (e). Collapse of abdom- 
inal viscera. To right or left: — (a). 
Hypertrophy and dilatation. (b). 
Effusion of gas or liquid into pleural 
sac — i.e. pneumothorax, hydrothorax, 
etc. (c). Unilateral emphysema, (d). 
Pleural adhesion and retracted lung. 
(e). Marked solid enlargements of 
lung or of the left lobe of the liver.* 

The apex beat may be invisible 
by reason of: — (a). Interposition of 
rib. (b). Fat chest wall. (c). Feeble 
heart, (d). Emphysema, (e). Edema 
of chest wall. (f). Pericardial effusion 




Fig. 



(marked), (g). Pleural effusion, (h). Transposition of the viscera (is 
present on right side). Its area and apparent force may be 
increased because of: — (a). Nervous excitement, (b). Hypertrophy or 
dilatation, (c). Retraction of lung. 

Systolic Retraction. — This may result from dilated heart, old 
pleuro -pericardial adhesion, or, shrinkage and contraction of the left 
lung. It is one of the signs of adhesion of the pericardium to the heart 
itself, which causes a systolic drag upon the diaphragm but to be of 
diagnostic value in this connection it should involve the posterior inter- 
spaces as well. 

Other Precordial Pulsations. — A strongly acting nervous heart and 
thin chest wall may cause systolic pulsation in the third, fourth or fifth 
left interspace and in the upper portion of the epigastrium even though 
the heart be normal, but ordinarily it is associated with cardiac 
dilatation, adjacent pulmonary cavity, pulmonary fibrosis, emphysema 
of the lungs, anaemia, neurasthenia or excessive emaciation. 

Pulsation in the Region of the Manubrium. — Such an impulse 

* Respiratory lateral displacement may occasionally be evident in right 
sided pleural effusion. See p. 134. 



PALPATION AND PERCUSSION. 



179 



if marked always suggests aneurism of the aortic arch, and pulsation 
of the manubrium itself is of special significance, because of its asso- 
ciation both with aneurism and certain forms of mediastinal growth. 

Precordial Bulging. — Aside from the presence of actual growths 
this is usually due to one of two causes, viz., aortic aneurism, or, excessive 
enlargement of the heart. It is most marked in those cases originating 
in early childhood in which the growing osseous structures have yielded 
readily to the pressure beneath. One may then often fix the date of 
the heart lesion seen in advanced life, and find perhaps, that it has 
existed for a half century. 

Palpation. — Palpation serves to confirm inspection and to detect 
thrills associated with valvular lesions or anaemia, points of tenderness 
and the general characteristics of tumors of any kind. It is of special 



Mediasti- 
nal tumor. 



Value in 
diagnosis. 





Fig. 72. — Dotted lines indicate per- 
cussion area. (Auscultatory.) 



Fig. 73-— Dotted lines indicate per- 
cussion area. (Auscultatory.) 



value in connection with expansile pulsation and diastolic shock of 
aneurism and the presystolic thrill and systolic shock of mitral stenosis. 
No examination of the diseased heart is complete that does not include 
the palpation of such related organs as the lungs, liver and spleen and 
determine the question of meteorism. 

Percussion. — Percussion is often decisive in the differential diagnosis 
of heart lesions. One should always percuss from the more resonant 
to the less resonant areas, save in determining the superficial dulness, 
and seek to determine (a) the deep or relative cardiac dulntss, (b) its 
superficial duhicss, (c) the resonance of the region of the aortic arch. 
Abdominal distension and pulmonary, hepatic, or splenic engorgement 
are also important factors if the heart is abnormal. If ordinary per- 
cussion be used the anatomical border of the heart is not accurately 



Scope and 
value. 



Caution. 



Never 

omitted. 



Cardiac 
bound' 



j 



i8o 



MEDICAL DIAGNOSIS. 



Manu- 
brium. 



Of utmost 
value. 



Murmur 
may be 
absent. 



outlined, but by auscultatory percussion, this may be very closely ap- 
proximated (see percussion and auscultatory percussion, pp. 92, 98), and 
the student should accustom himself to the sound of the normal dull 
tympany of the manubrium sterni, as this is one of the most important 
regions. In determining the superficial cardiac area it is best to com- 
mence at its known centre and percuss from that in radiating lines. 

Significant Changes in Percussion Area. — An increase in the area 
of superficial dulness may mean (a). Enlargement of the heart, (b). 
Retraction of the lung. (c). Pericar- 
dial effusion. Changes in the shape 
of the relative cardiac dulness usu- 
ally indicate enlargement of the 
heart itself, suggest the individual 
chambers involved and hence the un- 
derlying valvular lesions (see plates 
72, 73, 74). As will be seen later, 
such changed outlines serve as a 
check upon the diagnosis of valvular 
lesions and pericardial effusions, 
and the student must never forget 
that serious dilatation thus indicated 
may be unattended by any valvular 
murmurs. He should also carefully 
note and localize any pain or tenderness attending this procedure. 
Syphilitic periostitis, for example, may be encountered over the sternum 
and ribs and might prove of the utmost importance in a diagnosis. 

Auscultation. — This determines (a). The condition of the heart 
muscles, (b). The competence and condition of its valves, (c). The 
tension present in the aortic and pulmonary circuits, (d). The condition 
of the lungs {congestion, edema, effusions), (e). Abnormalities of the 
aortic arch. (f). The presence or absence of murmurs in the tributary 
veins and arteries. The first and most important consideration is the 
quality of the heart sounds in the valvular areas and in the carotid 
arteries. As in the case of the lung, a common mistake in the teaching 
of students lies in the failure to drill them thoroughly in the normal 
characteristics of, or common variations in, the heart sounds, and stu- 
dents and physicians alike are too often satisfied if no murmur is heard 

I and do not demand normal heart sounds and accentuation. In no 
other way can one explain the frequent failures to recognize the serious 

[ meaning of abnormal quality and accentuation, decided diminution or 




Fig. 74. — Dotted lines indicate per- 
cussion area. (Auscultatory.) 



Tender- 
ness. 



Wide diag- 
nostic 
scope. 



Know the 
normal. 



Avoid 
blunders. 



^O ^ 



HEART SOUNDS. 



181 



Normal ac- 
centuation. 



Production 
of sounds. 



A b norms 
accentu- 
ation. 



entire absence of heart sounds, conditions associated with some oj the 
most serious organic lesions oj the heart. 

HEART SOUNDS.— The First Sound.— A thorough understand- 
ing of the mode of production and normal accentuation of the heart 
sounds is absolutely essential to the intelligent interpretation of heart 
murmurs. At the apex the normal accentuation is on the first sound; at 
the base on the second. Disregarding conflicting theories and fine dis- 
tinctions, one may say that the essential elements in the production oj the 
first sound are the contraction oj the ventricular walls and the coincident 
closure oj the auriculo -ventricular valves. It follows that abnormally 
increased accentuation oj the first sound, as heard in any oj the jour 
auscultation areas, indicates an overacting ventricle whether due to 
mere increase in strength, as in hypertrophy from valvular disease, 
nervous overaction, excessive contraction of a partly filled ventricle, as 
is the case in mitral stenosis, or to heightened arterial tension, as in 
arterio-sclerosis, chronic toxaemia and interstitial nephritis. 

The Second Sound. — The second sound is produced by the simultane- 
ous closure and tension oj the aortic and pidmonary valves immediately 
jollowing ventricular contraction. Hence this second sound must prima- 
rily depend upon the integrity of the valves themselves, and measure 
the amount of that recoil which is the resultant of the forces of propul- 
sion and the resistance encountered in the artery. The aortic valve 
being sound, any increase in general arterial tension will produce an ac- 
centuation oj the aortic second sound, and similar increased tension 
in, or obstruction to, the pulmonary circulation will residt in an accen- 
tuation oj the pulmonary second sound. The degree will depend largely 
upon the soundness oj the valves, the strength oj the ventricles and the 
integrity oj the mitral and tricuspid leaflets* 

Practical Application. — Much information is afforded in both acute 
and chronic disease by a study of the variations in accentuation. For 
example, lobar pneumonia must inevitably be accompanied by marked 
accentuation of the pulmonary second sound and a dangerous tendency 
to dilatation of the right ventricle. If this dilatation becomes extreme 
the pulmonary second sound is markedly weakened and if tricuspid 
regurgitation occur it may be wholly lost, a sign of the gravest import. 
The pulmonary congestion incident to mitral stenosis and regurgitation 
makes accentuation of the pulmonary second sound an important 
diagnostic feature and as in pneumonia, a loss of tin's accentuation may 



Cause. 



Accentu- 
ation. 



Dimin- 
ished 2<3 

sound. 



Accentu- 
ated ad 

sound. 



*The mitral and tricuspid tones are increased under the same conditions 
but to a less marked extent. 



. 



182 



MEDICAL DIAGNOSIS. 



Modified 
ist sound 
and aortic 
2d. 



All sounds 
faint. 



Displaced 
heart. 



Important. 



be a serious symptom. The first sound, as heard at the apex, may be 
wholly lost or replaced by a murmur in mitral regurgitation, and both 
aortic stenosis and incompetence lend to obscure the second sound in the 
aortic area and in the carotid artery. In mitral stenosis the aortic second 
sound is weakened, the mitral being accentuated and sharp or slam- 
ming unless marked regurgitation coexist; in aortic regurgitation the first 
sound at the apex is obscured and in combined mitral and tricuspid 
regurgitation all sounds are greatly diminished. Mere weakening of 
both sounds, especially at the apex may be due to a fat or edematous 
chest wall, emphysema or pericarditis, or, may suggest cardiac dis- 
placement. In fibroid phthisis, pleural effusion, mediastinal growths, 
diaphragmatic hernia or even extreme meteorism or ascites, the cardiac 
displacement may be suggested by 
the changed site of the audibility 
of the sound or murmurs. Further- 
more one can seldom with certainty 
assign murmurs heard under such 
conditions to the individual valves — 
as they may wholly or in part dis- 
appear when the dislocation is cor- 
rected. Pleuritic effusion offers the 
most frequent examples. 

Increased Audibility. — Aside 
from causes already given this may 
result if, from any cause, the lung is 
retracted from the heart, and hence 
at times coincides with a change in 
the site of maximum audibility, 
e.g. fibroid lung or adjacent exca- 
vation. Sounds are occasionally transmitted loudly and over wide areas 
by pulmonary consolidation or cavity, and, in pneumopericardium. 

Changes in Timbre. — A tone may be harsh, ringing, "slamming," 
"foetal" or metallic. Metallic clacking is frequently audible in palpi- 
tation, especially if the stomach be distended by gas. Persistence of 
such qualities usually means disease of the valves or heart muscle, 
or, high arterial tension. Fcetal sounds and a slamming first mitral are 
always pathologic. 

Reduplication of Heart Sounds. — The normal heart sounds consist 
of two systolic and two diastolic sounds so blended as to form one systolic 
and one diastolic tone because of the synchronous closure of the valves 




Fig. 7s.— Division and Reduplication 
of the Heart-sounds. Fig. i. Redupli- 
cation of the first sound. Fig. 2. Divi- 
sion of the first sound. Fig. 3. Division 
of the second sound. 



HEART MURMURS. 



183 



of the right and left heart. Under many conditions this synchronism 
is so interfered with as to produce doubling or actual division of one or 
both sounds. The phenomenon of reduplication has aptly been com- 
pared to the sound produced by the closure of double swinging doors. 
A normal heart, if temporarily overacting, may be the seat of doubling 
or splitting of the heart sounds; but in general it may be said that 
hearing a reduplicated second sound or triple rhythm at the apex, 
one should suspect the presence of mitral stenosis* or myocardial 

degeneration. Gallop rhythm is a 
form of reduplication heard over the 
whole heart though sometimes more 
plainly over one side (Potain) that 
may be graphically represented. It 
is usually strongly suggestive of 
marked incompensation, interstitial 
nephritis, emphysema, arteriosclero- 
sis and exophthalmic goitre. Foetal 
or pendulum rhythm. In this the 
heart sounds are rapid and equally 
distant, i.e. if as is usually the case 
there is lack of the characteristic 
resonance, they resemble the actual 
fcetal heart sounds and the condition 
has been well named "embryo-car- 
dia" (Stokes-Von Huchard). The 
expert clinician recognizes various 
modifications and minor degrees of the utmost significance and im- 
portance as indicating a marked enfeeblement of the heart muscle. 

Auscultation Areas. — The four surface areas for auscultation are: — 
(1). The mitral area (apex). (2). Tricuspid area (lower half of sternum") . 
(3). Pulmonary area (second left intercostal space). (4). Aortic- 
area (second right intercostal space). These points do not correspond 
to the exact location of the valves, which may all be included in the area 
of a large stethoscope bell, but represent the areas in which the sounds 
of the respective valves or their associated murmurs arc best heard. 
Heart Murmurs. A heart murmur is an extraneous sound o\ cardiac 
site lending to obscure or partly or wholly replace the normal heart 
sound and directly related to il in rhythm. 



Occasion- 
ally trivial. 




Usually 
pathologic. 



Inferences. 



Fig. 76. — Reduplication and Divi- 
sion of the Heart-sounds. Fig. i. 
Reduplication of the second sound. 
Figs. 2 and 3. Gallop rhythm.— 
{After Vierordt.) 



A serious 
sign. 



Clinical 
areas. 



Definition 



* Less commonly in regurgitation unle 
marked degree or arterio-sclerosis. 



associated with myocarditis of 



j. 



1 84 



MEDICAL DIAGNOSIS. 



Transient 
murmurs. 



Common Sources of Error.— It should never be forgotten that the 
sounds produced by an overacting, tumultuously beating heart can 
seldom be accurately interpreted. Under such conditions, existing 
organic murmurs may be obscured or be unplaced in rhythm; or, as 
more commonly happens, murmurs may be present, purely temporary 
in character, which may be and often are regarded and treated as 
organic. Such transient dynamic or accidental 
murmurs and harsh heart sounds associated 
with abnormal accentuation are extremely com- 
mon. They call for rest, reassurance, the ad- 
ministration of such drugs as digitalis and the 
bromides, and always for repeated examina- 
tions. All patients should be examined if pos- 
sible both when recumbent and when erect, as 




Attitude 
important. 



Useful m; 
noeuvres. 



Loud 

vs. 

Soft. 



Time, qual- 
ity and site. 



Fig. 77.— Anaemic Mur- 
murs.— {Sansom.) 
Coexisting pulmonary 

the murmurs of regurgitation are usually best and apex murmurs. (Nine 

. . ■ . per cent, of cases.) 

heard m the former position, those of stenosis 

in the latter, while sometimes, as in the case of mitral stenosis, a 
murmur may only appear at the moment when the patient reaches the 
upright position and then rapidly subside. The diastolic murmur of 
aortic regurgitation may be increased by raising the arms above the head, 
or, require brisk exercise to make it audible. 

The Intensity of the Murmur. — The 
stronger the heart and the narrower the open- 
ing, the louder is the murmur, and speaking 
broadly it may be said, that the louder the 
murmur the better is the prognosis. Cases 
yielding soft murmurs elicitated with difficulty, 
or those in which no murmur is present though 
the heart is incompetent, are usually of the 
The rule is of course 




Fig. 78. 



Anaemia. — 
{Sansom.) 
Murmur over right ven- 
tricle and conus. (Eleven 
per cent, of cases.) 



most serious import 

subject to many exceptions. 
Anaemic or Haemic Murmurs. — The murmurs associated with an 
cemia are systolic in time and soft and blowing in character* are 
seldom widely transmitted, and are usually best heard over the pul- 
monary area (second left intercostal space). They are heard less 
frequently over the apex, aortic area, etc., and differ from the true 

* Rarely they may be loud and harsh as in a case of exsanguination due 
to acute hemorrhagic gastric ulcer observed by the author. In this case the 
murmurs were auto-audible and to be heard with the ear several inches 
from the chest. 



HEART MURMURS. 



185 




Fig. 79. — Anaemia. - 
(Sa?isom.) 

Murmur in aortic 
area. (Eleven per 
cent, of cases.) 



Lack trans- 
mission. 



Associated 
anaemia. 



Thera- 
peutic test. 



Manoeu- 
vres. 



murmur of mitral regurgitation in the fact that they have not the same 
transmission to the axilla and back. So also when heard over the 
aortic area (second right intercostal space), they 
lack the transmission into the carotids and sub- 
clavian characteristic of true aortic stenosis. 
Their association with anaemia and disappearance 
under appropriate treatment further serve to dif- 
ferentiate them in practice. Associated dilatation 
is uncommon, and when present, is slight. A few 
cases of diastolic haemic murmur have been re- 
ported.* 

Pleuro-pericardial Murmurs. — When the ap- 
posed layers of the pleura and pericardium become 
inflamed in the extension of a pleuritis or pericarditis, a murmur may 
be present which is usually distinctly frictional in character, and heard 
best in inspiration. This sometimes endures 
for a long time after the original disease, usually 
lacks the quality and transmission of a valvular 
murmur, but often closely simulates pericardial 
friction per se. By holding the breath in full 
inspiration the inflamed surfaces may separate 
and the murmur be lost if the area involved is 
sufficiently small. So also the differences noted 
in deep breathing may be much greater than 
pericarditis alone could explain. 

Other Forms of Accidental Murmurs. — A cat -dio-respir -alary mur- 
mur is a svstolic whiffing murmur heard best during inspiration and in 
the region of the heart border. Another cardio- 
respiratory murmur not a friction murmur is that 
heard in full expiration, in the same area, and 
despite authoritative opinion to the contrary, the 
author believes these to be often of great signifi- 
cance and, importance, and has again and again 
found them in association with the lesions oi 
pulmonary tuberculosis, both in its ancient and 
arrested, and, in its incipient and active form. 
He does not pretend to deny, however, that such a murmur often 
has little significance. Some curious crackling murmurs mav be 




Fig. so. — Anaemia. — 
(Sansom. 1 

Usual site of murmur- 
pulmonary area. (Fifty- 
nine per cent, of cases.) 




Many sug- 
gest pres- 
ent or past 
disease. 



Fig. Si.— Anaemia.— 

{Sansom.) 

Systolic apex murmi 

(Seven per cent, of rase 



*One reported bythe author occurred in tlu- terminal stage of pernicious 
anaemia. 



. 



i86 



MEDICAL DIAGNOSIS. 



Curious 
crackles. 



Splashing. 



Two kinds 



Pump. 



Relation 
to lungs. 



Course 
of blood. 



Mended 
sounds. 

Ventricu- 
lar con- 
traction. 



HUfB At 



V V V V 



heard along the left edge of the sternum, particularly, in connection 
with advanced emphysema. Similar sounds are heard over the right 
ventricle at a point between the apex and the sternum to which various 
unsatisfactory explanations have been assigned. If the pericardium 
contain both air and liquid a splashing sound of cardiac rhythm may be 
audible but is simulated by sounds produced in large contiguous 
cavities as in marked gastric distension, pneumothorax and advanced 
phthisis. 

ORGANIC HEART MURMURS.— Varieties.— Organic murmurs 
may be valvular, arterial, pericardial or pleuro-pericardial in origin. 
The valvular murmurs are of 
two kinds, (i) regurgitant and 
(2) obstructive — i.e. (1) those 
due to a leakage or back flow, 
and (2) those due to a narrow- 
ing of the valvular opening, a 
stenosis. 

Mode of Production. — The 
heart must be regarded simply as 
a double pump in constant ac- 
tion, or, as two double-chambered 
hearts cemented together and 
acting synchronously. They may 
be shown diagrammatically as 
two hearts with the lungs between 
them, for such is the plan of the 
circulation. Pouring constantly 
into the upper chambers comes the blood from the greater and lesser circu- 
lations. Into the right auricle the superior and inferior venae cavae pour 
their dark, impure, venous blood, while to the left, the four pulmonary 
veins bring a constant supply of bright, red, arterial blood, that has un- 
dergone purification in the pulmonary' air-cells. The blood passes from 
the auricles into the ventricles through the auriculo-ventricular valves, 
the mitral on the left, the tricuspid on the right, and is then forced by 
the ventricular contraction (systole) through the pulmonary valve on the 
right, and into the aorta upon the left. As both sides of the heart contract 
simultaneously, the sounds produced by valvular closure are ordinarily 
coincident and blended into one. The "first sound" (lub) corresponds 
to the period of ventricidar contraction and the closure of the mitral and 
tricuspid valves — i.e. systole. The instant that this contraction is effected 



*Syst 

Tricuspid") .. Tricuspids 
Mitral Closed r1itral 0pen 



Aortic ) Aortic ^ 

Pulmonary j 0pen Pulmonary j CloS( 



Fig. 82. 



•Position of the valves in systole 
and diastole. 



1 



ORGANIC HEART MURMURS. 



I8 7 



Relax- 
ation. 



the emptied ventricles relax and the aortic and pulmonary valves, closing 
sharply to prevent backflow from the full arteries, produce by their sudden 
tension the " second sound" (dup), which initiates " diastole." During « 
this, the period of relaxation, the blood that has been accumulating in the 
auricles again pours down through the open mitral and tricuspid 
valves to fill the emptied ventricles, and, just before the next systole the 
auricles themselves contract vigorously and ventricular contraction imme- 
diately follows. 

Practical Application and Importance of a Mental Image. — 
For the auscultator, systole is initiated by the first sound and diastole by 





Fig. 83. —The Normal Heart in Sys- 
tole. The full ventricles are con- 
tracting, the hlood flows freely from 
them into the pulmonary artery 
and aorta; the mitral and tricuspid 
valves are tightly closed ; the auri- 
cles are refilling, mv. Mitral valve. 
T v. Tricuspid valve, a v. Aortic 
valve, pv. Pulmonary valve. LA. 
Left auricle. R A. Right auricle. 
LV. Left ventricle. R V. Right 
ventricle. VCS. Vena cava supe- 
rior. V C I. Vena cava inferior. 
P,Vn. Pulmonary veins. AO. Aorta. 
PA. I'ulmonary artery. 



Fig. 84.— The Normal Heart in Di- 
astole. The ventricular contraction 
has ceased, the aortic and pulmonary 
valves, tightly closed, are shutting off 
and supporting the hlood column; the 
ventricles are filling from the open 
mitral and tricuspid orifices above. 
M v. Mitral valve. t v. Tricuspid 
valve, a v. Aortic valve, p v. Pul- 
monary valve. L A. Left auricle. 
R A. Right auricle. LV. Left ven- 
tricle. R V. Right ventricle. V C S. 
Vena cava superior. VCI. Vena cava 
inferior. P Vn. Pulmonary veins. 



the second. In the mind's eye he sees the cycle of events. Thus with the 
first sound he sees the ventricles contracting, the aortic and pulmonary 
valves freely open and the blood surging into the pulmonary artery and 
aorta. With the second sound he sees an exact reversal of conditions: 
the aortic and pulmonary valves arc tightly closed, the mitral and tricuspid 
freely open and the blood is rushing through them from the auricles 
above to the ventricles below. 

Important Deductions. — Any organic valvular murmur thai . 
diately follows, replaces or modifies the normal first sound ^systolic 



lives. 



Auricular 
contrac- 
tion. 



Phenom- 
ena of >> 
tole. 



01 di 
tole. 



J 



i88 



MEDICAL DIAGNOSIS. 



Inevitable 
conclus- 
ions. 



Systolic 
murmurs. 



Diastolic. 



Rule of in- 
cidence. 



Logical 
sequence. 



Heart 
response. 



Tension. 



Hyper- 
trophy. 



Relative 
insuffi- 
ciency. 



murmur), must arise either from leakage in the closed valves (mitral and 
tricuspid) or from an obstruction in those that should be freely open 
(aortic and pulmonary)- Hence any organic endocardial systolic 
murmur must be due either to mitral or tricuspid regurgitation or to 
aortic or pulmonary obstruction (stenosis). In diastole the opposite 
conditions prevail; the mitral and tricuspid valves being open and the 
aortic and pulmonary valves closed. It must follow, that conversely, 
any murmur immediately following, modifying, or replacing the second 
sound (diastolic) is due to aortic or pulmonary leakage or to mitral or 
tricuspid obstruction. Nine out of ten murmurs have their origin in 
the left heart — the hard working side. 

Against the Stream. — It is at 
once evident that if at any point there 
exist an impediment to the free flow 
of the blood, an increased strain is 
thrown upon the cardiac mechanism 
and a tendency to congestion or stasis 
is at once established. Therefore, if 
any damming of the flow is present 
or any portion of the pumping ma- 
chinery is defective, the bad effects 
will appear chiefly in those por- 
tions of the heart nearer the venous 
sources of the blood. In short, if 
one may use an old expression, the 
bad effects of a cardiac lesion work 
backward against the blood stream. 

Illustration.— Interstitial nephritis raises arterial blood pressure 
to an extraordinary degree and the left ventricle at once responds 
to the challenge of the narrowed arteries by increasing the strength 
of its contraction. The blood is then forced so vigorously into the 
aorta as to make the recoil or tension of the aortic valve unusually 
violent, and as a result there is an u accentuation of the aortic second 
sound." Like every other muscle under unusual exercise, the ventricle 
tends to hypertrophy and to increase its strength: the wear and tear 
of the aortic valve is also increased and an unusual and excessive pressure 
is exerted upon the mitral valve, which stands between the overacting 
ventricle and the left auricle. //, as sometimes happens, the mitral 
valve yields to the pressure, a backflow into the auricle is at once estab- 
lished and the flow of blood from the lungs is at once obstructed. The 




Fig. 8s.— Right and Left Hearts 
S. V. C, I. V. C. Superior and inferior 
venae cavre. P. A. Pulmonary artery. 
P. V. Pulmonary veins. AO. Aorta. 



RHYTHM. 



189 



i st Sd. ^ d 5d 



I st Sd. Z d 5d. 



right ventricle is immediately called upon for increased action in order 
to relieve the congestion of the lungs. The blood is then forced so 
strongly into the pulmonary artery as to intensify the shock of its valvular 
closure and produce an u accentuation of the pulmonary second sound" 
The lungs may thus be placed between two fires through the continued 
regurgitation oj blood from the front and the increased pressure from 
the overacting right ventricle behind. A persistence of these conditions 
would tend to cause a temporary or permanent leakage through the 
tricuspid valve, and the effects of back pressure are then manifested in 
the general venous circulation by congestion and edema, or, general ana- 
sarca. Such a cycle of pathologic events is common enough in practice 

though by no means invariable, and, 
realizing what marked local symp- 
toms may arise from even a slight 
chronic congestion of the brain, 
stomach, liver, intestines, kidneys 
and lungs, one can readily under- 
stand how easily in such cases val- 
vular disease as a cause may be 
overlooked. 

The Causative Factors. — Prac- 
tically all true valvular murmurs 
are due to stenosis or abnormal 
patency of one or more of the valvular openings and these conditions 
result from inflammation of the valves (endocarditis), chronic sclerosis 
(arterio-sclerosis) , or from stretching of the valvular ring (relative in- 
sufficiency). The causative conditions are fully described, see pp. 213, 
214, and a study of the causative factors makes clear the etiology of 
the actual lesions. 

RHYTHM.— Organic Murmurs Occurring with Systole.— (First 
sound— period of ventricular contraction) : — (a) mitral regurgitation, (b) 
tricuspid regurgitation (c) aortic stenosis, (d) pulmonary stenosis (rare). 
Systolic murmurs are nine times in ten due either to mitral regurgi- 
tation or aortic stenosis, or, are purely accidental or anaemic. 

Murmurs Heard in Diastole. (Second sound — period of ventric- 
ular relaxation): — (a) aortic regurgitation, (b) pulmonary regurgit- 
ation (rare), (c) mitral stenosis (rarely purely diastolic, usually pre- 
systolic), (d) tricuspid stenosis (rarely). 

Purely diastolic murmurs arc almost invariably duo to aortic regur- 
gitation. 



Pulmonary 
congestion. 



Secondary 

tricuspid 

lesion. 




Symptoms 
often misin- 
terpreted. 



Fig. 86.— Mitral and Tricuspid Regur- 
gitation. Percussion area— cardiac and 
hepatic. ( Ward cases.) 



Endocar- 
ditis and 
sclerosis. 



J 



190 



MEDICAL DIAGNOSIS. 



Double 
lesions. 



Variable. 



Frequent 
errors. 




Murmurs Heard Immediately Before and Running Into the 
First Sound. — (presystolic, auricula -systolic. Period of auricular 
contraction initiating systole): — (a) mitral stenosis, (b) tricuspid 
stenosis. 

A presystolic murmur is almost invariably due to mitral stenosis. 

Relative Frequency. — Mitral regurgitation is by far the most com- 
mon; mitral stenosis, aortic regurgitation, aortic stenosis and tricuspid 
regurgitation follow in order, the remaining lesions being rare. As to 
combined lesions, double mitral and 
double aortic are most common, 
some placing the latter first in fre- 
quency, which is against the author's 
personal experience and would vary 
greatly in different clinics according 
to the predominant sex and age. 
Mitral stenosis is frequently over- 
looked and also misdiagnosed in 
connection with aortic regurgitation 
where the false presystolic or Flint 
murmur is frequently encountered. 
True aortic stenosis is present only 
in a minority of the cases presenting 
an aortic systolic murmur and, from 
the nature of the lesion, regurgita- 
tion must usually be associated with 
it. Thus all statistics so far pre- 
sented are fallible and to some ex- 
tent misleading. 

Sex and Age. — Mitral disease 
predominates in women, aortic in 
men. In children, females are 
chiefly affected and in 93^ of Holt's series the lesion was mitral regur- 
gitation, aortic leakage being extremely rare. As age advances aortic 
lesions increase in frequency, but the mitral valve still predominates. 

The Differential Points. — To differentiate heart murmurs the fol- 
lowing points are determined: — (a) Time or rhythm, (b) Point of 
maximum clearness and intensity, (c) The direction and extent of trans- 
mission, (d) The quality of the abnormal sound, (e) The associated 
signs, viz. : — arterial and venous pulsation, the radial pulse, increased 
area of cardiac dulness, accentuation of heart sounds, cyanosis, edema, etc. 



Fig. 87.— Mitral and Tricuspid Regur- 
gitation. — Heart in systole. Mitral and 
tricuspid valves both incompetent. AV- 
sult— Double systolic murmur, enlarge- 
ment of both right and left chambers, 
pulsating jugulars, general venous con- 
gestion, edema, anasarca, etc. mv. Mi- 
tral valve, tv. Tricuspid valve, a v. 
Aortic valve, p v. Pulmonary valve. 
LA. Left auricle. R A. Right auricle. 
LV. Left ventricle. R V. Right ven- 
tricle. V. C. S. Vena cava superior. 
V. C. I. Vena cava inferior. P. Vn. 
Pulmonary veins. P. A. Pulmonary 
artery. A O. Aorta. Xote :— Dilatation 
of the right heart and tricuspid leakage 
are much more common than was for- 
merly supposed. 



All impor- 
tant. 



^ 



MITRAL REGURGITATION. 



I 9 I 



l 5t Sd 



Sd Z d 5c 




Fig. 88. — Mitral Regurgitation. 
Percussion area (cardiac and hepa- 
tic). {Ward cases.) 



To Determine the Rhythm or Time. — This should be positively 
determined by taking the apex beat or carotid pulse while listening to 
the murmur. The radial pulse should not be used. 

Hypertrophy and Dilatation.— Figs. 72, 73, 74 show the variation in 
outline in these conditions; their influence upon heart sounds has been 

discussed and the peculiar differences 
in the apex beats. Simple hypertro- 
phy is usually associated with chronic 
interstitial nephritis or arterio -sclerosis 
and simple dilatation represents the 
stage of incompensation in such lesions, 
or, some form of myocarditis. 

Characteristic Symptoms of the 
Systolic Valvular Murmurs.*— MI- 
TRAL REGURGITATION.— Time. 
— Systolic. Quality. — Blowing, of all 
degrees of intensity, occasionally musi- 
cal. Maximum Intensity.— At apex but sometimes heard only at the 
left inferior angle of the left scapula. Transmission. — To the left 
through the axillary space and just to the right of the edge of scapula 
between its spine and inferior angle. Associated Signs. — The pul- 
monary second sound is sharply accentuated: there is hypertrophy of 
the right heart, and to a lesser degree of the left, 
the apex being displaced to left and slightly down- 
ward. Cardiac dulness is increased chiefly to the 
right; the cardiac area being well shown in the 
accompanying diagram (fig. 88). // the lesion be 
fully compensated there are few symptoms aside from 
the physical signs; if not, the pulse is usually irregu- 
lar and of poor tension, cyanosis is present to a 
variable and often extreme degree, there is passive 
pulmonary congestion or actual consolidation and 
marked dyspnoea or even orthopnea. The tricuspid 
may yield and with loss of the pulmonary accentuation the signs and 
secondary effects of right heart failure may ensue. The edema varies 
with the degree of cardiac weakness, from slight swelling oi the ankles 
01 legs to general anasarca. A patient is seldom so ill as (0 be beyond 
hope, for no valvular Lesion is more responsive to radical and rational 
treatment. This does not apply to those eases of sudden relative 
*Tobe read in connection with " Compensation and lncompensation." 



carotid. 



Disease as- 
sociations. 




g. 89.— M i t r al 
Regurgitation, {San- 
som.) Maximum in- 
tensity and transmis- 
sion. 



Edema 

variable 



Hope tul 
prognosis 



J 



192 



MEDICAL DIAGNOSIS. 



Bad cases. 



insufficiency due to acute dilatation in which the prognosis is not good, 
death or chronic invalidism being a common sequel because of the 
absence of that gradual compensatory hypertrophy permitted by an 
endocarditis or arterio-sclerosis. Another extremely unfavorable mitral 
lesion is that which sometimes occurs as a terminal event in chronic 
interstitial nephritis. 
AORTIC STENOSIS.— Time.— Systolic. Quality.— Usually harsh 




Fig. 90. — Mitral Regurgitation. Four 
varieties of the murmur of mitral regur- 
gitation are shown graphically. The 
heart in systole, mitral leakage evident. 
The contracting ventricles are forcing 
the blood through the open aortic and 
pulmonary valves; the tricuspid, tightly 
closed, prevents regurgitation into right 
auricle. The leaky mitral allows back- 
flow into the left auricle already filling 
from the pulmonary veins above. Re- 
sults. — A systolic murmur, dilatation of 
left auricle, pulmonary congestion, and 
consequent enlargement of right ven- 
tricle, m v. Mitral valve, tv. Tricus- 
pid valve, a v. Aortic valve, p v. Pul- 
monary valve. LA. Left auricle. R A. 
Right auricle. L V. Left ventricle. 
R V. Right ventricle. V. C. S. Vena 
cava superior. V. C. I. Vena cava in- 
ferior. P. Vn. Pulmonary veins. P A. 
Pulmonary artery. A O. Aorta. 




Fig. 91.— Aortic Stenosis.— A shyg- 
mographic tracing is shown, and three 
varieties of the aortic systolic murmur 
are represented graphically. Diagram- 
matic representation of the heart in sys- 
tole, stenosis of the aortic valve being 
present; the mitral and tricuspid valves 
have closed; the right ventricle is nearly 
empty; the left ventricle is still more 
than half full of blood, because of the 
obstruction present at the aortic orifice. 
Result. — A systolic murmur in the aortic 
area; enlargement of left ventricle, etc. 
m v. Mitral valve. TV. Tricuspid valve. 
a v. Aortic valve, p v. Pulmonary 
valve. LA. Left auricle. R A. Right 
auricle. L V. Left ventricle. R V. 
Right ventricle. V. C. S. Vena cava 
superior. V. C.I. Vena cava inferior. 
I*. Vn. Pulmonary veins. P. A. Pul- 
monary artery. A O. Aorta. 



and blowing. Maximum Intensity. — Right second intercostal space. 
Transmission. — Upward into carotid and subclavian, unless a very 
faint murmur. May, if intense, be heard over the whole chest. Asso- 
ciated Signs. — Hypertrophy or dilatation of the left ventricle. Apex 
beat markedly displaced downward and to the left. Pulse usually 



TRICUSPID REGURGITATION. 



'93 



l st 5d. t* 



l 5t 5d 2 d 5d. 




Fig. 92 
sion area. ( Ward cases 



Aortic Stenosis. Percus- 



deliberate, artery small and full between beats. Second sound in aortic 
area relatively diminished. 

Prognosis. — It is a lesion of long duration, but is not as common 
as is generally supposed, many systolic aortic murmurs being due to 
sclerosis of the aorta itself. 

Differential Diagnosis. — Its transmission alone is decisive save as 

regards sclerosis of the aorta which 
shows an accentuated second sound. 

TRICUSPID REGURGITA- 
TION.— Time.— Systolic. Quality. 
— Blowing and usually soft. Maxi- 
mum Intensity. — Over lower third 0) 
sternum and occasionally chiefly to the 
right of its lower half. Transmis- 
sion. — May sometimes be heard over 
the whole right heart, and at times, if 
patient be recumbent, over the manu- 
brium. Associated Signs. — Hyper- 
trophy or dilatation of right heart. Diminished accentuation or loss of 
pulmonary second sound, distended or directly pulsating jugular veins. 
In bad cases, or as the lesion advances, it may, by back pressure 
through the general venous system, lead to extreme chronic conges- 
tion of the liver, spleen, stomach and intestines, edema of the lower 
extremities and, general anasarca. // is frequently secondary to a mitral 
lesion, but may be induced by heavy strains, par- 
ticularly if the myocardium be primarily diseased. 
It is not uncommon in heavy drinking teamsters 
or laborers, especially brewery employes, "beer- 
driver's heart, " and indeed ts more common than 
is usually stated. 

Prognosis. — Poor if the disease is primary 
but it often disappears entirely under treatment if 
the insufficiency is secondary and relative. 

Differential Diagnosis.— Is often confounded with mitral regurgi- 
tation but its characteristic location and transmission, the pulmonary 
second sound diminution distinguish it from everything except pul- 
monary stenosis, an excessively rare, usually congenital, lesion having its 
maximum at the second left intercostal space. 

PULMONARY STENOSIS.— Systolic murmurs in the pulmonary 
area arc almost invariably functional. The organic murmur is extremely 

13 



Common 

error. 



- 



Systolic 

venous 

pulse. 




Primary 

vs. 
Secondary, 



Common. 



Fig. 93.— Aortic Ste- 
nosis. Transmission. 



Diagnos 






194 



MEDICAL DIAGNOSIS. 



Rare. 



Important 
transmis- 
sion. 



Blue 
children. 



Presystolic 
murmurs. 





Fig. 94. — Pulmonary 
Stenosis in Adults.— 

(Sansom.) 
Shaded area repre- 
sents field of maxi- 
mum intensity. 



rare and usually congenital. If present it is commonly associated with 
other congenital defects, such as a patent foramen ovale or perforate 
interventricular septum. The differential diagnosis is at times ex- 
tremely difficult, sometimes 

quite impossible. The typical 

signs are the following: — 
Quality . — Rough, harsh 

murmur. Time. — Systolic. 

Maximum Intensity. — At 

second or third left interspace. 

Transmission. — May be _.. 

J Fig. 95. — Pulmonary 

heard OVer whole right heart, Stenosis. * Maximum 

. point and direction of 

out is usually markedly trans- transmission, 
mitted from pulmonary area 
upwards and outward toward the clavicle. It is not transmitted along 
the aorta and into the carotids. Associated Signs. — Diminished pul- 
monary second sound. Hypertrophy of right heart. Cyanosis is easily 
produced by cough or exertion and may be permanent. It will cer- 
tainly be so if a patent foramen ovale co-exist with the pulmonary 
stenosis. Its victims usually die young of pulmonary tuberculosis. 
Characteristic Symptoms of the Diastolic Valvular Murmurs. 

— The diastolic valvular 

murmurs are, theoretically, 

mitral stenosis, aortic regur- 
gitation, tricuspid stenosis 

and pulmonary regurgitation. 

An exception must be made 

in the case of stenosis of the 

Fig. 96.— Mitral Stenosis. ., 7 , . ,., .,- 

- {Sansom-Braviwell.) mitral OT tricuspid onjlCC pig 97 -Mitral 

^MZZHSZL™ Such murmurs are rarely g-SSg-JEi 

diastolic, possibly because of audibility of simu- 

• 1 •!!• lated doubling of 

the flow of blood from auricle to ventricle during second sound. Lower 
diastole is not sufficiently forcible to produce a mur- mur 'transmission. 
mur until just before systole, when the ventricular 
suction is reinforced by auricular contraction. For this reason the 
rhythm of mitral or tricuspid murmurs due to stenosis is presystolic 
or auriculosystolic — i.e. beginning late in the diastolic period, they are 
heard just before, and cease abruptly at, the first sound. 

MITRAL STENOSIS.— Quality.— Harsh, vibratory or blubbering 
murmur terminating abruptly in marked crescendo. Time. — Presystolic. 





AORTIC REGURGITATION. 



195 




Increasing in intensity as it runs into a sharply accentuated first sound. 
Rarely diastolic and still more rarely divided. Point of Maximum 
Intensity. — At or just within the beat. Transmission. — Limited to 
the mitral area and usually very sharply defined. Associated Signs. — 
Cyanosis present to some degree but often slight. Accentuated pulmon- 
ary second and mitral first sounds. It is frequently accompanied by a 

systolic mitral murmur (regurgita- 
tion). Marked hypertrophy 0} right 
ventricle, i.e. percussion dulness ex- 
tends to right of normal boundaries. 
Pulse. — Small, rapid, irritable and 
irregular. Thrill usually present, 
felt best at or near point of maxi- 
mum intensity of murmur. A diag- 
nosis may often be made by palpa- 
tion, a presystolic thrill in the mitral 
area being pathognomonic of mitral 
stenosis. Second sound frequently 
doubled. 

Sources of Error. — The dias- 
tolic murmur of mitral stenosis may 
be confounded with a rare form of 
aortic regurgitant murmur that is 
distinctly heard at the apex. The 
presystolic murmur is often variable 
or intermittent, may be heard only 
in either the standing or the recum- 
bent position, and may be entirely 
obliterated by pressing too heavily 
with the bell of the stethoscope. 
The sharp flapping first sound is 
usually so strikingly characteristic 
as to suggest the presence oj mitral 
stenosis even when no murmur is present. 

AORTIC REGURGITATION.— Quality.— A blowing murmur oj 
variable pilch and intensity, usually somewhat prolonged, occasionally very 
short, perhaps musical, which may entirely or partly replace or but 
slightly modify the second sound. Time. — Diastolic. (Commencing with 
or immediately following the second sound.) Maximum Intensity. — 
At aortic area (second right interspace), third lejt interspace, or at msi 



Fig. 98.— Graphic Representation of 
Three Varieties of the Murmur of Mi- 
tral Obstruction. (With Sphygmo- 
gram.) Heart at moment of auricular 
contraction immediately before systole 
(presystole); mitral obstruction evi- 
dent; aortic and pulmonary valves 
closed; tricuspid freely opened; right 
auricle nearly empty; right ventricle 
filled; left auricle but partly emptied; 
left ventricle barely half full. Result. — 
Presystolic or diastolic murmur, dilata- 
tion of left auricle, congestion of lungs, 
consecutive enlargement of right heart. 
m v. Mitral valve. t v. Tricuspid 
valve. A v. Aortic valve. p v. Pul- 
monary valve. L A. Left auricle. R A. 
Right auricle. L V. Left ventricle. 
RV. Right ventricle. V.C.S. Vena 
cava superior. V. C. I. Vena cava in- 
ferior. P. Vn. Pulmonary veins. I*. A. 
Pulmonary artery. A O. Aorta. 



Diagnosis 
sign. 



Attitude. 



Stetho- 

scopic 

pressure. 



Almost 
pathogno- 



196 



MEDICAL DIAGNOSIS. 



form. It is increased by raising the arms to a vertical position and by 
exertion and very rarely this murmur is heard only at the apex. Trans- 
mission. — Along lines shown in fig. 101, i.e., from second right inter- 
space to second left or third left cartilage, down left edge of sternum; is 
frequently heard at apex and in the carotids. Associated Signs. — Pallor, 
visible jerking pulsation of peripheral vessels — (i.e., temporal, carotid, 



Rich in 
signs. 



Useful ma- 
noeuvre. 



Ophthal- 
moscopic 
signs. 




i st 5d. ^ d 5(l 



Sd. 2 d Sd. 




Fig. 99. — Mitral Stenosis, 
cussion area. ( Ward cases.) 



Per- 



Fig. 100.— Aortic Regurgitation. 
Percussion area. {From ward cases.) 



Corrigan" or 



subclavian, axillary, brachial, radial, etc.). Capillary pulse: second 
sound diminished or lost in carotids: sometimes a pseudo-mitral 
stenosis (Flint) murmur. Capillary pulse: — If the nails be examined 
closely, if a glass slide be pressed upon the lips, or if the skin 
be reddened by friction, a rhythmic flush may be seen. Radial 
Pulse. — A jerking, throbbing, slapping pulse (the 
"water-hammer" pulse) which may be felt in 
shaking hands or in grasping the tips of the 
ringers or toes. In order best to appreciate the 
lack of sustained tension it is well to raise the 
arm and grasp the wrist with the hand in such 
a way that the ball of the examiner's thumb 
overlies the radial artery, the finger and thumb 
meeting on the back of the hand. Cardiac 
Area. — The cardiac area is increased downward 
and to the left because of left ventricular hyper- 
trophy. Pistol-Shot sound in femorals. This curious sharp shock -like 
sound may be heard in the femoral arteries in marked cases. Dizzi- 
ness, fainting, palpitation, cardiac pain, and neurasthenic symptoms are 
common in this lesion. The ophthalmoscope may show jerking retinal 
arteries. The second aortic sound is markedly diminished and usually 




Fig. 101. — Aortic Re- 
gurgitation. * * * max- 
imum intensity direction 
of transmission. 



TRICUSPID REGURGITATION. 



197 



lost in carotids. Aortic regurgitation is frequently associated with aortic 
stenosis. 

General Symptoms and Comment. — As in other lesions, no 
marked subjective symptoms may be present while compensation is main - 
tained but, more often than in them, a dull pain or sense of oppression 
in the cardiac area or sharper neuralgic pains referred to the neck, 

shoulder, and especially the left 
shoulder and arm, or even true 



Pain. 




angina pectoris, may be noted, 
Excitement and physical exertion 
may initiate or provoke recurrence 
of these symptoms. Vertigo, tinni- 
tus aurium, throbbing headaches, 
syncope, subjective or true dys- 
pnoea, and palpitation may be 
present. The patient is usually 
nervous, high strung, and, if he 
knows his condition, apprehensive 
and easily depressed. The mental 
state is often that of neurasthenia 
and in rare instances actual melan- 
cholia is observed. Sleep is often 
disturbed by dreams or an actual 
insomnia exists frequently aggra- 
vated by the auto-audible beating 
of the carotids or other vessels, of 
which these patients often com- 
plain. In the stage of incompen- 
sation there is little tendency to 
general anasarca or marked pul- 
monary congestion unless, as fre- 
quently happens, there is a co-ex- 
istent or secondary mitral lesion. 
Edema of the ankles is common, however, and dyspnoea, palpitation, 
oppression, etc., tell the talc of cardiac weakness. 

TRICUSPID STENOSIS. Rare, usually congenital. Quality and 
Time. — Exactly likeniitral stenosis. Point of Maximum Intensity. — 
Lower sternum, chiefly along right border. Transmission. — Slight, along 
right sternal border. Associated Signs. Marked cyanosis. Disten- 
sion of jugulars. Percussion Area. -That of right auricular dilatation. 



Vertigo, 
etc. 



Nervous 
state. 



Fig. 102.— Graphic Representation of 
Murmur. Two Varieties of Aortic Dias- 
tolic Murmur Shown Graphically. (With 
Sphygmogram.) The heart is shown in 
diastole, aortic leakage being evident. 
The blood has just been projected into 
the aorta and pulmonary artery by the 
ventricular contraction. The pulmonary 
valve tightly closed maintains the blood 
column, but through the leaky aortic 
valve a regurgitant current meets the 
stream descending from above through 
the open mitral valve. Results.— A dias- 
tolic murmur, dilatation and hypertro- 
phy of left ventricle, a slapping, low-ten- 
sion pulse, m v. Mitral valve, t v. Tri- 
cuspid valve, a v. Aortic valve, pv. 
Pulmonary valve. L A. Left auricle. 
R A. Right auricle. L A. Left ven- 
tricle. R V. Right ventricle. V C S. 
Vena cava superior. VCI. Vena cava 
inferior. 1' Vn. Pulmonary veins. PA. 
Pulmonary artery. AC). Aorta. 



Edema 

late or ab- 
sent. 



. 



198 



MEDICAL DIAGNOSIS. 



Ready dif- 
ferenti- 
ation. 



Timing 
murmurs. 




A 



Fig. 103. — Aortic Regurgita- 
tion. Aneurismal dilatation. 
Mitral leakage. 



PULMONARY REGURGITATION.— Rare, usually congenital 
Quality and Time. — Exactly like murmur of aortic regurgitation. 
Point of Maximum Intensity. — Second left interspace. Transmis- 
sion. — Over sternum and down its left 
edge. Differentiated from aortic regurgi- 
tation by the percussion area, which is 
that of a hypertrophied right ventricle, 
and by the associated signs. These are 
cyanosis and overdistension of jugulars. 
In this lesion the second aortic sound is 
clearly heard. Marked jerky pulsation of 
.fljBKC^' peripheral arteries, the "Corrigan pulse," 

■ fe\ and the capillary pulse are wanting. 

Rarer Murmurs.— As a matter of fact, 
the organic pulmonary murmurs and that 
of tricuspid stenosis are so rare in adults 
that one has practically to consider only 
mitral, tricuspid and aortic regurgitation 
and mitral and aortic stenosis. As pre- 
viously stated a systolic murmur is due, 
nine times out of ten, to mitral regurgitation or aortic stenosis, and 
as one is heard best at the apex and transmitted to the axilla and 
back, and the other is best heard at the aortic cartilage and transmitted 
upward, no confusion need occur. The purely diastolic murmur is almost 
certainly due to aortic regurgitation and its peculiar transmission and 
the associated signs make it quite unmis- 
takable. The chief source of error lies in a 
failure to take the time of every murmur by 
the carotid beats, carefully note its maximum 
intensity and transmission and, in the case 
of two murmurs like in rhythm, the pitch 
and quality. 

Associated Murmurs. — Any combina- 
tion of murmurs may be encountered though 
in most instances a post mortem greatly re- 
duces the excessive number of presumptive 
lesions sometimes reported. 

CONGENITAL HEART DISEASE (morbus cceruleus.).— The 
"little victim'' is not always blue, for certain defects such as those of the 
auricular septum may exist without cyanosis. On the other hand a baby 




Fig. 104.— Aortic and Mitral 
Regurgitation. Percussion 
area. ( Ward cases. ) 



CONGENITAL HEART DISEASE. 



199 



Usual in- 
ference. 



may in exceptional cases be decidedly blue with no evidence of heart 
disease, as in a case known to the author in which a large mass of adenoid 
tissue in the naso pharynx was accountable for the condition which disap- 
peared at once after operation. The rule holds however that an active 
infant or ambulant child that is extremely cyanotic is the victim of 
congenital heart disease and in most instances loud, harsh, often musical 
murmurs are heard, often without the thrills or characteristic changes ! Cardinal 
in cardiac outline pertaining to the ordinary heart lesions which they r 
may simulate. Clubbing of the fingers and toes and dyspnoea fre- 
quently co-exist. 

The lesions aside from those already discussed may be thus epito- 
mized: — Auricular septum defects — no definite symptoms. Ventric- 
ular defects — simulate mitral regurgitation but lack symptoms of 
pulmonary engorgement. Not to be positively diagnosed. 

Persistent Ductus Arteriosus. — Post systolic murmur continuing 
beyond the second sound and transmitted slightly into carotids; radial 
pulse smaller in deep inspiration. Aneurismal dilatation of the duct 
may produce paralysis of vocal cords through recurrent laryngeal nerve, 
There may be late systolic thrill, dyspnoea and cyanosis and slight second 
pulmonary accentuation. 

Persistent Aortic Isthmus. — Arteries and pulse of upper extremity 
(branches from the arch) are large. Those of the lower extremity and 
trunk small, the pulse being markedly delayed. The left ventricle is 
hypertrophied and there are visible collateral arterial communications 
(e.g. internal mammary — sup. and inf. epigastric, dorsalis scapulae and 
posterior intercostals, etc.) which may yield systolic murmurs and thrills. 

Comment. — Unfortunately these lesions, sufficiently vague and inde- 
terminate in themselves are usually combined and seldom permit a 
specific localizing diagnosis The murmurs are systolic or post systolic 
save in pulmonary regurgitation and are usually loudest at the base. 
Pulmonary lesions cause a marked enlargement of the right heart 
and a striking diminution of the pulmonary second sound with marked 
thrill in stenosis. Ventricular septum deject may lack both thrill and 
hypertrophy. Patent ductus arteriosus may show marked thrill and 
no hypertrophy. A persistent aortic isthmus is plainly indicated. 

Other Congenital Anomalies.— The heart or the great vessels may 
be transposed, consist of one, two, or three chambers, through com- 
plete septal defects, or, the heart may be placed in the neck, abdomen. 
or, without the chest cavity. 

COMPENSATION AND INCOMPENSATION.-A clear under 



200 



MEDICAL DIAGNOSIS. 



Must be un- 
derstood. 



Three 
stages. 



Slight 
symptoms. 



Error 
frequent. 



Frank or 
vague. 



Pain. 



1 >yspncea. 



Secondary 

lesions, etc. 



standing of these two factors as affecting diagnosis, prognosis, and treat- 
ment is absolutely essential, and a lack of it leads to sins of commission 
no less than omission. Owing to the wonderful interaction of the regu- 
lating mechanisms controlling the blood vessels and the heart almost 
ever} 7 form of heart defect may be so compensated for varying periods 
as to equalize the circulation and minimize symptoms. A clinician 
recognizes three distinct phases in the course of any heart lesion: (i) 
perfect compensation, (2) impaired compensation, (3) lost compensation. 
As regards the four chief varieties of valvular lesions, namely, mitral 
regurgitation and stenosis, and aortic regurgitation and stenosis, the 
first stage may show nothing more than the peculiar murmurs, the 
characteristic change in the cardiac outline, which indeed may be 
slight for a long period, and certain characteristics in connection with 
the pulse or general peripheral circulation. This statement is equally 
true of certain forms of myocarditis with intermittent relative valvu- 
lar insufficiency and indeed applies to a greater or less extent to all 
lesions. Sins of commission occur in connection with this state and 
consist of meddlesome interference in the way of treatment and the 
creation of unnecessary alarm through irrational and terrifying state- 
ments as to prognosis. Such hearts need little or no treatment but 
do need watching from time to time. 

(2). Impaired Compensation. — This stage is the one most com- 
monly encountered and the sins committed in connection with it are 
chiefly those of omission due to a failure to recognize and interpret 
obscure manifestations of the condition. In many lesions these symp- 
j toms are actually obtrusive; for example, the victim of aortic regurgi- 
tation complains of dull pain and oppression in the precordium or 
sharper neuralgic pains radiating to the neck, left shoulder and down 
the left arm, or, he has some subjective or objective dyspnoea, attacks of 
pronounced angina pectoris, vertigo, headache, insomnia, probably an 
increase of the nervous irritability so common in these cases, or, signs 
of secondary mitral lesions may appear. In mitral stenosis the dyspnoea 
may be marked, especially on exertion, the pulse becomes rapid, more 
markedly irregular and unequal, pulmonary congestion and blood 
streaked sputum may be evident and this may even be reflected in 
the condition of the kidney, stomach, liver and spleen. In mitral 
regurgitation much the same symptoms are evident and if the right 
heart is markedly weakened or tricuspid regurgitation is established, 
there is marked diminution of the pulmonary second sound, direct 
pulsation of the extended jugulars, pulmonary congestion, enlarge- 



IMPAIRED COMPENSATION. 



20I 



merit of the spleen and liver, indigestion, flatulence and in short 
general, visceral, passive congestion. These symptoms are suffi- 
ciently striking and to them, are added in any case an extention of the car- 
diac borders due to a dilatation which may be manifested by the 
substitution of a weakened heart impulse for that of hypertrophy, and 
oftentimes, by a change in the quality of the murmur. In aortic 
lesions edema is likely to be absent or slight so long as the mitral 
holds fast. In mitral lesions edema of the lower extremities may be 
present with even slight degrees of incompensation. In the later 
stages general anasarca may appear. These are plain straight- 
forward symptoms, each with its clear meaning, but it is quite otherwise 
when one deals with the slighter forms of such incompensation and still 
more so in relation to the dilatation and slight incompensation associ- 
ated with chronic myocarditis; cases which frequently present no 
murmur until rest and cardiac stimulants have renewed the tonus of 
the heart muscle and narrowed the valvular ring. 

The nervous system is peculiarly affected in many cases of slight 
incompensation. Some of the most typical cases of neurasthenia ever seen 
by the author have been associated with a silent or almost silent leakage 
or stenosis of the mitral valve, and indeed several were associated with 
unrecognized aortic aneurism. Nothing is commoner in these cases 
than nervous irritability, drowsiness or insomnia, lack of concentra- 
tion and ability to perform sustained mental or physical work, while 
numbness and tingling of the extremities are frequent. Again and again 
these cases have been associated with only slight increase of the cardiac 
area, enfeebled or somewhat fcetal heart sounds, and most often, 
markedly diminished or absent mitral first sound. The skin may be the 
seat of persistent pruritus or eczema and very often a very slight grade 
of edema may be present, limited usually to the lower extremities, 
bilateral, and often most marked over the surface of the tibia. 

The Lungs.— Persistent dry cough, slight or even marked con- 
gestion of the bases, asthmatic seizures, diffuse bronchitis, moderate 
grades of emphysema and persistent pharyngitis and laryngitis may 
divert attention from an underlying incompensation, which is either 
causative, or a factor in the severity and continuance of pulmonary 
symptoms. 

The Gastro-intestinal Tract. — Indigestion and persistent constipa- 
tion together with recurrent attacks of acute gastric and hepatic dis- 
turbance and hemorrhoids are frequently associated with inefficient 
heart action. The author firmly believes that many of the results 



Heart 

borders. 



Edema. 



Obscure 
types. 



Mistaken 
for neuras- 
thenia. 



Treated as 
pulmonary 

lesions. 



Mistaken 
tor gastric 
disease. 



202 



MEDICAL DIAGNOSIS. 



Hopeless 
cases. 



Extreme 

incompen- 

sation 

sometimes 

temporary. 



When to 
surrender. 



obtained by the rest cure in neurasthenia may be attributed to the 
good effect upon the stomach and heart with the resulting improvement in 
nutrition. Certainly under mental and physical rest all of the symp- 
toms described promptly disappear in all minor degrees of incompen- 
sation. 

(3). Complete Incompensation. — This term should be applied 
to those cases in which the heart muscle has completely lost its recupera- 
tive quality as is seen in the terminal stages of all chronic heart affections 
that terminate gradually, or by sudden though not immediately fatal 
rupture of compensation. The best examples are seen in terminal 
cases of coronary sclerosis, fatty heart and chronic myocarditis in 
general. So also in mitral lesions there comes a time when the heart 
that has alone or with assistance again and again recovered itself finally 
yields and resists all therapeutic measures. In such terminal and 
"irrecoverable" cases the or- 
thopnceic patient often rolls 
the head aimlessly from side 
to side and wears a pecu- 
liarly listless yet distressed 
and hopeless expression. 
The term is frequently er- 
roneously applied to cases 
of very marked and extreme 
cardiac weakness and espe- 
cially to that of mitral re- 
gurgitation or stenosis asso- 
ciated with secondary tri- 
cuspid leakage and general 
anasarca. In mitral regur- 
gitation especially, the as- Fig. 105.— Hopeless incompensation. Attitude 
- , • 7 . frequently assumed. Triangular area represents 

SUmptton Of terminal mcom- superficial cardiac dulness. 

pensation is seldom justified 

as a primary assumption, for there is no cardiac lesion in which proper 
treatment can do so much, however extreme may be the manifestations. 
Indeed in the case of all heart lesions it is only after trying and fail- 
ing that surrender is justifiable on the part of the physician. 

Relative Insufficiencies. — The secondary dilatation of the valvular 
rings, such as occurs in the tricuspid following prolonged mitral lesion 
or as a result of myocarditis and severe physical strain, or in the mitral 
as secondary to aortic lesions, chronic myocarditis or the terminal stage 




RELATIVE INSUFFICIENCIES. 



203 



of an interstitial nephritis the prognosis is variable. In such cases 
under proper treatment the tricuspid usually recovers its function in 
whole or in part, as does the mitral to a less degree and with less COn- 




Fig. 106— Aneurism involving ascending and transverse portions of the arch, coin- 
cident aortic regurgitation. Symptoms of aortic regurgitation only at time photo- 
graph was taken. Later those of aneurism became e\ ident. 



Btancy. The left heart cases associated with sudden rupture of com- Sudden 
Sensation through severe strain do badly ij the myocardium is not sound. 
and often terminate quickly and fatally. So also the mitral insutu- 



204 



MEDICAL DIAGNOSIS. 



Interstitial 
nephritis. 



Devotees. 



Trauma- 
tism. 



Heredity. 



Valuable 
aid. 



Old divis- 
ions. 



Important. 



ciency so often encountered in chronic interstitial nephritis will not 
respond to treatment with anything like the promptness usually noted 
in connection with this valvular lesion, and, moreover, the patients of 
this type are often irritable, restless, difficult to control and quite 
unlike the ordinarily phlegmatic, cheerful mitral-regurgitant patient. 

THORACIC ANEURISM.— A true aneurism represents a local 
dilatation of an artery due to the weakening effect of a chronic degenera- 
tive arteritis. 

Etiology. — Any factors that lead to arterial degeneration on the one 
hand and abnormally great vascular tension upon the other may produce 
aneurism. As is often said, the victim is usually one who has wor- 
shipped at the shrine of Venus, Bacchus or Vulcan, and to these the 
author would add Mammon if not Minerva. Syphilis unquestionably 
stands first as a cause and is responsible for a large majority of the cases. 
Intemperance in eating or drinking, physical and mental overwork or 
overstrain act as contributing causes, the first symptom in many cases 
dating from sudden, severe or prolonged muscular effort. Several 
cases coming under the author's observation have dated their symptoms 
from severe falls or railway accident. It is quite possible that a con- 
genital weakness of the vessels is a factor in the aneurisms of the young 
but in all these cases it is difficult to believe that we can exclude a 
primary' inherited degenerative process due to one of the factors origi- 
nally mentioned. The disease is much more common than is generally 
supposed and is frequently the cause of sudden death referred (without 
autopsy) to other conditions. 

Difficulties Encountered in Diagnosis. — The use of the fluoroscope 
and the X-Ray photograph has added greatly to our diagnostic resources 
and made it possible to recognize aneurism in its earlier stages. Other- 
wise no disease is more easily recognized in the presence of its classical 
symptoms, nor more frequently overlooked when these are absent. The 
old clinical divisions are (a). Aneurism with signs and symptoms, (b). 
Aneurism with symptoms but no signs, (c). Aneurism with neither 
symptoms nor signs. It should be remembered that (a) . Classical symp- 
toms develop only in certain cases and then usually when the terminal 
stage is reached, (b). That large aneurisms may exist without them, 
(c). That death from aneurism is frequently unsuspected both ante and 
post mortem in the absence of an autopsy, (d). That ordinary diag- 
nostic resources are therefore unsatisfactory and inefficient and (e). 
That the fluoroscopic picture or X-Ray photograph offers usually the only 
means of early diagnosis at our command. 



THORACIC ANEUEISM. 



205 



Sudden 



Statistics of Aneurism. — Roughly speaking three-fourths of all 
aneurism are aortic, and nineteen -twentieths of these are found in the 
thoracics aorta; of these 90% are saccular; from 80-90% occur in the 
male, and 50% occur between the ages of 35 and 50. The people 
whose habits most largely represent intemperance in food and drink 
and occupations which involve the maximum of intemperance and lia- 
bility to syphilitic infection furnish the chief examples to the incidence 
and mortality of the disease. 

Favorite Sites. — The root of the aorta, the junction of it ascend- 
ing and transverse portions, and the descending arch represent the 
chief points of attack in the frequency indicated by their order. 

Termination. — The peculiar situation of these tumors with a ref- 
erence to adjacent and related structures readily explains their symp- 
tomatology and termination. Death occurs suddenly in almost every 
instance because of rupture of the sac. The blood may pass into the c 
pericardium or adjacent pulmonary artery, into the superior vena cava, 
the esophagus, any one of the four heart chambers, the lung itself, 
the mediastinum, or, externally, in aneurisms causing pressure necrosis. 
-4s regards relative frequency the pericardium, pulmonary artery, and 
right auricle head the list in the order given. 

Symptoms. — A pulsating gradually enlarging tumor within a limited 
space filled with important anatomical structures means a predominance 
of pressure symptoms, which may be tabulated as follows:— Esophagus, 
dysphagia. Trachea: — brazen cough (gander cough), dyspnoea, stridor, 
bronchorrhcea and hemoptysis (if not from sac itself). Root of the 
lung, and the pleura: — Symptoms suggesting phthisis, pulmonary col- 
lapse, pleurisy, etc. Pericardium: — Pericarditis. Chest wall:— Local- 
ized, dull pain. Nerve trunks: — Neuralgic pains, paroxysmal and inter- 
mittent. Pulmonary artery, systolic pulmonary murmur, dilated right 
heart. Sympathetic fibres: — Dilated or contracted pupil, unilateral 
sweating or pallor. Cardiac plexus, anginal attacks. Superior vena 
cava: — Edema of upper extremity, cyanosis. Thoracic due: — Maras- 
mus. Vagus: — Dyspepsia, nausea, vomiting, dyspnoea, hiccough. 
Phrenic: — Unilateral diaphragm paralysis. Recurren: laryngeal: — 
Hoarseness, aphonia, spasm or paralysis left cord, paroxysmal dyspnoea. 
It must not be forgotten that any or all of these symptoms may be caused 
by mediastinal growths other than aneurisms. 

' PHYSICAL SIGNS OF ANEURISM. Inspection.— This must 
be both direct and tangential and one seeks primarily to discover 
local bulging or pulsation. The region of the manubrium and the 



Predomi- 
nant pres- 
sure symp- 
toms. 



May be ab- 
sent. 



A 



2o6 



MEDICAL DIAGNOSIS. 



back between the left scapula and the spine should be examined with 
special care. 

The Primary Signs Are:— (a). Abnormal pulsation usually in 
the locality mentioned, but variable in position, degree and extent; 




Fig. 107. — Diffuse dilatation of aorta, aortic stenosis and regurgitation. Dilated 
vessels show here as a faint shadow. 

if typical, heaving and expansile, (b). Rarely, a visible tumor yielding 
expansile pulsation and covered by tissues which may be normal, tense 
and shiny, congested or even necrotic. 

Secondary Signs. — (a). The peripheral signs of an associated aortic 



ANEURISM. 



207 



Tracheal 
tug over- 
rated. 



regurgitation may be present, (b). The apex beat may indicate left 
ventricular hypertrophy, a condition commonly but not invariably asso- 
ciated with thoracic aneurism, (c). Signs 0} sclerosis in the peripheral 
arteries, (d). Cyanosis, localized edema and unequal pupils, vaso- 
motor symptoms such as unilateral pallor, congestion or sweating, (e). 
Stridor, visible dyspnoea, (f). Paralysis of the vocal cords associated 
with hoarseness or aphonia, (g). Brazen cough. 

Palpation. — Expansile pulsation and thrill and the so-called disas- 

tolic shock are chiefly to be sought. In certain aneurisms involving 

the transverse portion of the arch, one may find the "tracheal tug" 

first described by Oliver. To obtain this, the cricoid cartilage is grasped 

by the thumb and finger of the observer as the head of the patient is 

tipped slightly backward, upward traction is then made and a tugging 

sensation may be felt with each cardiac impulse.* The observer is 

often misled by the pulsation of vessels under the finger, particularly 

« mm if aortic incompetence exists, and, by 

^"^ yV checked respiratory movements. Further- 

^^^^^^^^^^^L more, it is undoubtedly present in many 

ml 7\ /i^^^^K^jil /Am« healthy persons, and in those who have 

residual pleural adhesions and certainly 

absent in a very large proportion of the cases 

of true aneurism. 

The Pulse. — Aside from the signs of a 
coincident aortic regurgitation the pulse important 
yields information of real value in many 
cases. The observer should carefully com- 
pare the beat in the two radials and carotids 
and note any delay or inequality. Resulting as they do either from 
the pressure of the sac or deformed arterial outlets in the portions 
involved, such differences furnish excellent corroborative evidence and 
sometimes assist in localizing aneurysmal tumors. (See p. 171.) 

Percussion. — In advanced and well defined cases percussion may 
furnish direct evidence in the form of marked dulness over aneur- 
ismal areas, but in the earlier cases it is deceptive and misleading. 
Auscultatory percussion is usually more valuable than simple percussion. 
Student and practitioner alike should be thoroughly familiar with the 
normal variations in the peculiar percussion note yielded by the man- 
ubrium stemi. 



Fig. 108. — Aneurism of the 
Aorta. Percussion area in a 
case presenting typical signs. 
(Ascending portion.) 



Often use- 
less. 



* From the careful study of a considerable number of eases the author 
believes this to be a greatly over-rated symptom. 



208 



MEDICAL DIAGNOSIS. 



Important, 
not con- 
stant. 



Valuable 

suggestive 

sign. 



May long 
be absent. 



Auscultation. — A systolic or more rarely a diastolic murmur, or 
both, may be heard but are due in most instances to associated 
valvular disease, this being particularly true of the diastolic murmur, 
a systolic bruit often harsh, vibrant and associated with palpable thrill 
being not uncommonly produced by the sac itself. Pressure upon the 
pulmonary artery may also account for the murmur heard. The systolic 
murmurs are often widely transmitted along the vessels and a localized 
systolic heard at the left back is an important sign of aneurism of the 
descending thoracic aorta. The most important single sign, the author 
believes to be a distinct ringing, metallic, second sound, heard not over 
the aortic valve itself, but over the sac. The maximum intensity of the 
true sac murmurs may occupy the same suggestive site. 

Subjective Symptoms. — Dyspnoea, precordial oppression and pain 





Fig. 109. — Aortic Aneurism 
l Ascending Portion of Arch). 
Unusual percussion area. — . 
Only point of pulsation. Had 
taken out insurance within two 
years. 



Fig. no.— Aortic Aneurism. 
Same case as figure 109, three 
months later. 



are the chief subjective signs and of these, pain is by far the most important. 
Theoretically, every large aneurism should be accompanied by severe 
pain, actually a large number go to a fatal termination without it. 
When present it may be localized, diffuse or referred, shooting, cutting, 
or more commonly dull or gnawing. It is often misinterpreted, re- 
garded as neuralgic, and so treated. 

Special Symptoms According to Site of Lesion. — Aneurism of the 
first portion of the arch. Any statements made under this heading 
are liable to exception, but in general it may be said that if the first 
portion of the arch is involved a pulsation or rarely an expansile tumor 



ANEURISM. 



209 



is likely to appear at or about the second right interspace, which tends 
to extend its area of dulness outward and upward. In exceptional Dulness 
instances the mass passes downwards. Attacks of- angina pectoris 
and severe palpitation are common in this connection. The 
aortic valves are likely to be involved and symptoms of aortic re- 
gurgitation and a double murmur are often present, associated with 
systolic thrill and marked diastolic shock. Extension of the growth 
tends to cause localized edema, cyanosis, vaso-motor symptoms and 
possibly pleural or even pericardial inflammation. 

Aneurism of the Transverse Portion of the Arch. — The com- 
mon symptoms are dulness and pulsation over and about the man- 



Pain. 



Thrills and 
murmurs. 




Fig. m.-Aneurism. 
(Aortic). This man took 
out life insurance but a 
short time before photo- 
graph was taken. 




Fig. 112.— A n e u r i s m. 
Man well nourished and 
healthy in appearance. 



ubrium and in the episternal notch, tracheal tug in some cases, paralysis 
of the vocal cord with whispering voice and brazen cough, marked 
general pressure symptoms, pain, variable (less severe than in aneur- 
ism of the first portion), systolic bruit, thrill, diastolic shock (often 
lacking), pulse variations (often marked), dyspnoea and precordial 
pressure. Pseudo-asthmatic seizures are common and misleading in 
connection with this fo;m and the author has known of several such 
instances in which for a long time treatment had been unsuccess- 
fully and mistakenly employed. 

Aneurism of the Descending Portion of the Arch.— In this 
lesion the symptoms are likely to be present posteriorly rather than 
anteriorly. They may be slight or absent; may include bruit, percus- 
sion dulness, superficial posterior pulsation, or, actual tumor with 
14 



Symptom: 
often 

marked. 



Pseudo 

asthma. 






2IO 



MEDICAL DIAGNOSIS. 



Value of 
X-Ray. 



Early diag- 
nosis rare. 



History 
clear. 



Fluoros- 
copy. 



Error un- 
likely. 



Confusing 
condition. 



Offer diffi- 
culties. 



Important 
points. 



perhaps external perforation, and are commonly accompanied by a 
considerable degree of posterior dulness and gnawing pain.* 

General Considerations and Differential Diagnosis. — The last 20 
cases of thoracic aneurism coming under the author's attention have 
J been subjected in each instance to the X-Ray, and without it fully 50% 
would have gone unrecognized. By reference to illustrations on pages 
208, 209, one will see that advanced cases terminating fatally within 
! a few months, presented few or none of the typical signs of the disease. 
Many had been treated for various ailments, utterly unrelated to the true 
cause of the trouble, and neuralgia, asthma, dyspepsia, disease of the 
spine and pulmonary tuberculosis were amongst the diseases erron- 
eously diagnosed. It would seem that our ideas in regard to the symp- 
tomatology of thoracic aneurism need revision and that our diagnostic 
methods should be reinforced by the findings of the X-Ray. f 

Differential Diagnosis. — Mediastinal abscess. The rapid develop- 
ment with symptoms of suppuration and inflammation and the absence 
of aneurismal symptoms other than pressure symptoms should be 
sufficient to exclude this lesion. Pulmonary fibrosis. Cases of fibroid 
phthisis or any case involving the retraction of lung may give rise to 
suggestive pulsation in aneurismal areas, but ordinary methods should 
be sufficient to establish the actual conditions present and be reinforced 
by a fluoroscopic inspection of the arch. Pulmonary tuberculosis with 
large cavity adjacent to the aneurismal areas may produce pulsation 
and certain other aneurismal signs, but the history, sputa, breath 
sounds, etc., should make error impossible. Anaemic Pulsation 
should be readily differentiated by rational methods. Aortic re- 
gurgitation is frequently associated with aneurismal dilatation both 
dynamic and true; if unassociated it should offer little difficulty. 
Malignant growths in the mediastinum. When these are asso- 
ciated with evidences of malignant disease elsewhere in the body 
they offer little difficulty, but when not so associated they become 
most difficult to differentiate. They may yield all of the pressure 
symptoms and even pulsation in aneurismal areas. The following 
points assist in differentiating them: — (a). Knowledge of a primary 
focus of malignant growth, (b). Absence of the auscultatory signs 
of aneurism, (c). Rapid emaciation, (d). Absence of expansile pul- 

* In the author's experience, however, this has been of a remittent type, 
and relieved by absolute rest, at least in the early stage of the disease. 

t Of these cases 50% have already died suddenly, in several instances 
without developing the more marked symptoms. 



ANEURISM. 



211 



sation either upon ordinary inspection or more definitely as determined 
by fluoroscopic methods. In two cases seen recently by the author a 
certain amount of aneurismal dilatation co-existed with a large medias- 
tinal growth, in the one case a sarcoma, in the other, carcinoma. Certain 



Aneurism 
may co-ex- 
ist. 




Fig.113.— Malignant growth producing \ 
ward in the mediastinum. Heart and dil. 
shadow. Confirmed by repeated photogra] 



tenosis at the eardia and extending up- 

ted aorta are represented bj the deeper 

ihy and finally by autopsy. 



vascular growths with definite expansile pulsation may appear and force 
the diagnostician to rely wholly upon auscultatory signs. In such 
instances occasional errors in diagnosis, or failure in positive deter- 
mination are unavoidable. 



Excusable 

error. 



. 



212 



MEDICAL DIAGNOSIS. 



Final Considerations and Conclusions. — Certain cases of aneurism 
yield no symptoms save those determined by X-Ray examination. Here 
as elsewhere, a knowledge of the normal heart sounds is of the first impor- 




Fig. 114.— Malignant obstruction at cardia, growth occupying mediastinum. 

tance. All ringing, and distinctly metallic second sounds at the base 
should be regarded as suspicious when their points of maximum in- 
tensity are found at some distance from the proper valvular area. Tan- 



ENDOCARDITIS. 



213 



All impor- 
tant data. 



gential inspection should never be omitted and in doubtjul cases yielding 
percussion dulness the effect of absolute rest should be determined. In all 
walking cases of aneurism any existing area of dulness is perceptibly 
reduced by a few days of rest, and the daily variability of pressure 
symptoms as related to the occupation or the pursuits of the individual 
should be considered. The temperature record, strength and nutrition 
should be watched; unilateral loss of knee jerks is suggestive and the 
history of past syphilis or external signs of a denied lesion are most 
important. It should be remembered that senile pericarditis is often 
aneurismal, and that active pressure ulceration of the pulmonary struc- 
ture may produce physical signs of tuberculosis, and finally, that with 
the fluoroscope one may usually see and accurately measure the sac, 
determine true expansile pulsation and accurately record the changes 
induced by rest or treatment. 

ENDOCARDITIS. —Definition.— An inflammation of the endocar- 
dium, acute, subacute or chronic, benign or malignant, affecting chiefly 
the opposed surfaces of the valves, but more rarely the mural endocar- 
dium, and tending to produce transient lesions or permanent vegetations 
or deformities more or less seriously affecting valvular action. 

Varieties*. — In general there are three classes: (1). Verrucose, 
in which the valves are the seat of vegetations, finely papillary in 
appearance, yellowish white in color and composed of spindle cells types - 
derived from the fibrous tissue or endothelium, leucocytes, fibrin 
threads and granular material. They are often capped by layers of fibrin. 
(2). The ulcerative form, characterized by predominance and rapid 
extension of a necrotic process present to a slight degree in the preceding 
form, the clinical symptoms being largely those of septic intoxication. 
(3). The sclerotic or fibrous form characterized by its slow develop- 
ment, its chronicity and its tendency to deform valvular structures. 
It is impossible to clearly separate the acute benign from the acute ulcer- 
ative form, save on clinical grounds, and a chronic endocarditis of any 
type may follow an acute attack. 

Etiology. — No specific micro-organism can be charged with the 
responsibility for acute endocarditis. The pneumonococcus, staphy- 
lococcus, streptococcus, and more rarely the colon bacillus and the 
bacilli of influenza, tuberculosis and typhoid have been found in 



Three 



*G. A. Gibson aptly says: "It is impossible to draw any definite lino 
separating these lesions from one another. They form a chain oi which 
the ends, though extremely diverse, are yet united by links presenting a 
perfect gradation." 



w 



214 



MEDICAL DIAGNOSIS. 



Fre- 
quency, 



Age. 



Associated 
ailments. 



Emboli. 



Precordial 
oppression. 



Offers 
many diffi- 
culties. 



endocardial lesions. Acute rheumatism, the acute forms of septic 
infection, and the toxines of various acute infectious diseases are associated 
with both the benign and ulcerative cases. The sclerotic forms are 
caused by the same factors as are active in arterio-sclerosis generally. 
It is probable that an endocarditis exists in nearly every severe case of 
acute rheumatism (its most common cause) and that many spontaneous 
recoveries from transient unrecognized lesions occur. Children are 
especially liable to this acute complication of rheumatism, 60-80% 
presenting demonstrable lesions. In adults the percentage is probably 
about 50%, though a lower figure is usually given by authorities. 
Chorea and acute tonsillitis are both closely associated with this affection, 
though in choreic cases many murmurs are present which may prove 
ultimately to be functional or accidental. Any of the exanthemata 
and especially scarlatina and diphtheria may be complicated by it 
and gonorrhoea in the adult is sometimes associated with the ulcera- 
tive form. The peculiar structure of the vegetations in verrucose 
endocarditis makes it possible for fragments to be swept away by the 
blood stream and produce emboli in the brain, lungs or other viscera, 
thus accounting for some of the sudden deaths and paralytic seizures, 
encountered in chronic heart disease. 

Subacute Endocarditis. — This form presents few symptoms, other 
than a murmur, and fever may pass unnoticed unless it appear 
in an afebrile interval of the primary disease. Palpitation and in- 
constant symptoms of dyspnoea, or more often a sense of precordial 
oppression are usually present though often overlooked. All cases of 
acute infections or chronic diseases such as gout, diabetes and Bright's 
disease should be carefully watched; in the former the heart should be 
examined at each visit, for oftentimes serious valvular lesions are 
overlooked and the patient is allowed to be up and about under con- 
ditions full of danger and making certain the establishment of a chronic 
lesion. Ulcerative Endocarditis. — The symptoms are essentially 
those of (a). The typhoid state, (b). Of pyemia, and are usually defi- 
nite though latent cases occur. Chill, high fever and sweats associated 
with valvular murmur are the more characteristic features but it 
may closely simulate typhoid fever, malaria and meningitis. Petechiae 
are usually present, multiple abscess formation is common, splenic tume- 
faction, often sudden from infarct, may occur, gastro-intestinal symptoms 
may be predominant, and, rarely, a septic arthritis develops. The 
diagnosis depends largely upon the presence, or the development of a 
valvular lesion with septic and usually embolic manifestations. 



PERICARDITIS. 



215 



Chronic Endocarditis. — This permits a division under two distinct 
classes. (1). Cases following rheumatism or other acute infections. 
(2). Those due to sclerotic or fibroid changes resulting from alcoholism, 
syphilis, gout, chronic nephritis or mere senile changes. 

The resulting valvular alterations may cause the most extreme de- 
formity or be comparatively slight and the symptoms are merely those 
discussed under the head of valvular diseases. 

PERICARDITIS. — The etiologic factors in pericarditis are identical 
with those of endocarditis discussed in the preceding section, 50% of 
the cases being attributable to rheumatism and representing chiefly 
the younger ages; B right's disease and tuberculosis being active factors 
particularly at older ages. Traumatism and diseases of malnutrition 
play a somewhat larger part and the acute infections generally a lesser 
one than in endocarditis. Indeed it is a not uncommon terminal 
event in many chronic diseases. About 50% of the cases are dry or 
plastic and males are chiefly affected. It is a frequent accompaniment 
of cases showing valvular lesions or may be coincident with an acute 
or subacute endocarditis. 

Morbid Anatomy. — The changes are identical with those of pleu- 
risy both as to the nature and course of the inflammatory changes and 
the variable constitution of the exudate, hence we have not only dry 
pericarditis and pericarditis with effusion, but the latter may be serous 
(the common form), hemorrhagic, purulent or gaseous. 

Symptoms. — Like the pleura the pericardium forms a potential 
cavity, its layers being reflected upon the heart and upwards upon the 
great vessels for an inch or more and its parietal layers structurally 
continuous with and adherent to the diaphragm below and the cervical 
fascia above. In cases of effusion it is converted into an actual recep- 
tacle capable of holding from one to three pints or even larger quantities 
in exceptionally chronic cases; thus it may form within the mediastinum 
a tumor so large as to cause many of the pressure symptoms fully dis- Pressure. 
cussed under aneurism, page 205, and furthermore seriously embar- 
rasses the action of the heart itself and the adjacent pulmonary structures. 
Its close relation to the pleura makes its participation in a pleurisy 
common, as also the involvement of the pleura in a pericarditis. Having 
these facts in mind its symptoms suggest themselves. They are (a) Symptoms, 
pain, often severe, (b) fever, (c) accelerated pulse, (d) dyspna-a, (e) pre- 
cordial oppression, (f) friction sounds, (g) signs of effusion. 

Marked pain is present in about three-fourths of the cases but is 
variable in its site and intensity, being felt usually chiefly over the 



Anatomic 

relations 

important. 



Extension 

of process 



. 



2l6 



MEDICAL DIAGNOSIS. 



Cardinal 
symptoms. 



Chief sign. 



Character- 
istics. 



Effusion. 



Dulness. 



Rotch's 
sign. 



Ewart's 
sign. 



base of the heart, in the epigastrium or even referred to the left arm 
and shoulder as in angina pectoris. The jever is usually moderate and 
of variable duration, lasting from a few days to several weeks accord- 
ing to the course of the inflammatory process and is of a septic type 
if suppuration occurs. The pulse may not only be accelerated but 
markedly arrhythmic. The dyspnoea is often marked but not excessive 
unless effusion occurs when it may even reach orthopncea. Slight 
cyanosis may be present in the early stages and is marked in the 
presence of large effusions. Precordial oppression may be present even 
in the early stage and is intensified in large effusions. The friction 
sounds may be single, double or triple, are usually heard chiefly at the 
base and to the left of the median line and are superficial, rubbing, creak- 
ing, shuffling or grating sounds though at times assuming the qualities 
of a harsh valvular murmur or a crepitation. They are seldom as 
directly related to the heart sounds as endocardial murmurs, are likely 
to shift their points of maximum intensity and change their quality 
from day to day and are often associated with marked local tenderness 
and increased audibility under stethoscopic pressure. The double sound 
is most common, the second pulmonary sound is accentuated, murmurs 
have no definite transmission as in endocardial disease, and, friction fre- 
mitus is often present. If effusion occurs it usually relieves the pain 
and is manifested by changes in the cardiac outline varying with the ex- 
tent of effusion but tending to assume a pear-shaped or triangular form 
with the base downward. The dulness is more marked than in ordinary 
dilatation, the apex beat often appears higher than normal, is within 
the left border of dulness and may entirely disappear in large effusions. 
The acute angle ordinarily formed by the relative dulness of the right 
heart and the liver boundary is rendered obtuse (Rotch's sign), the heart 
sounds are diminished over the area of dulness and pressure signs 
become prominent as the effusion advances. An irritative cough some- 
times of brazen quality may be present, compression of the left lung 
may give rise to dulness under the left scapular angle with harsh or tubu- 
j lar breathing (Ewarfs sign), cyanosis deepens, dyspnoea increases 
and the patient is usually distressed, depressed and apprehensive. The 
symptoms of pressure affecting mediastinal structures (page 205), should 
be noted, the pulse may be dicrotic or paradoxic, and respirator} 7 
venous collapse (see p. 176) may suggest extensive inflammatory adhe- 
sions. Occasionally but not always the lesser effusions show marked 
changes in the level of dulness with changes in posture. 

Chronic Adhesive Pericarditis. — This common sequel offers great 



_ 



MYOCARDITIS. 



217 



diagnostic difficulties. Occasionally as in pleurisies it is suggested 
by the persistence of modified friction over the heart. If exten- 
sive the diaphragm may be so dragged upon by adhesions as to 
show the one pathognomonic sign, viz., systolic recession of the lower 
lejt thoracic zone or of the interspaces representing the diaphragmatic 
attachment. So also there may be persistent systolic filling and diastolic 
collapse of the jugular veins. In persistent adhesion there is a dilatation 
and hypertrophy of the hampered heart much less favorable as regards 
prognosis than that of endocardial disease. 

Diagnosis. — Aside from the factors mentioned the diagnosis of 
effusion may require the use of an aspirating needle of small calibre 
which is most safely introduced into the crevice formed by the ensiform 
and the rib margin on the right side, the needle being directed towards 
the point of the right shoulder. This procedure is not to be undertaken 
unless prompted by real necessity. The long persistence of an effusion 
and the occurrence of a septic temperature point to pyo -pericardium 
and the substitution of marked resonance (of the form of the sac), for 
the dulness points to pneumo -pericardium, an excessively rare condition. 
While theoretically and indeed usually the diagnosis of this condition 
is simple, in practice, cases of the utmost difficulty may be encountered 
and more than one highly skilled clinician has introduced the needle 
into a dilated heart usually, fortunately, without serious result. It is 
necessary, therefore, to bear in mind the peculiar featurs of pericardial 
effusion dulness, its more marked character, its greater upward extent, 
its peculiar form and its extension beyond the apex beat if that be visi- 
ble. Massive long standing effusions have been mistaken for left sided 
pleurisies. Hydro-pericardium occurs as a part of general dropsy and 
is seldom mistaken for actual inflammatory effusion because of the asso- 
ciated conditions and the usual absence of primary fever.* 

MYOCARDITIS. — The diseases of the myocardium may be divided 
into acute and chronic, the former occur chiefly in connection with 
the severer forms of infectious diseases such as scarlatina, typhoid, 
typhus, malignant endocarditis and septic intoxications in general and 
constitute one of the most common and serious complications of 
diphtheria, and the heart may show enormous dilatation, almost abso- 



Suggestive 
signs. 



Definite 

symptom. 



Heart and 
veins. 



Aspiration. 



Pus. 



Gas. 



Error 
possible. 



Important 
features. 



Transu- 
date. 



Acute. 



Associated 

ailments. 



* In a case observed by the author some years ago an aneurism of the 
aortic arch occupying the right lower chest and associated with a markedly 
dilated and displaced heart closely simulated in the character and extent of 
dulness a marked pericardial effusion; fortunately the aneurismul signs were 
sufficiently distinct to prevent any error, though friction sounds oi cardiac 
rhythm were present at the base. 



218 



MEDICAL DIAGNOSIS. 



Diagnosis 
clear. 



Suggestive 
symptoms. 



Varia- 
bility. 
Pulse. 
First sound. 
Murmurs. 



lute inefficiency, or indeed produce death instantly or with slight 
warning. 

Symptoms of Acute Myocarditis. — Marked arrhythmia, palpita- 
tion, vertigo and weak, rapid or excessively slow pulse, dyspnoea, 
cyanosis and diminished urine may be associated with a clear mind or 
in some cases delirium. The heart sounds are weak, foetal and lacking 
in normal accentuation and there is usually no difficulty in making out 
by percussion the outline proving dilatation. 

Chronic myocarditis may accompany: — (a) coronary sclerosis, em- 
bolism or thromboses, (b) chronic valvular disease or senile degeneration 
producing the condition known as brown atrophy, (c) fatty overgrowth 
and fatty degeneration. Fatty overgrowth lacks the actual degenerative 
changes of the latter form though marked fatty infiltration may impair 
the function and nutrition of the muscle and may even affect the papil- 
lary muscle and endocardium. In both cases the heart is soft, yellow 
and enlarged. In actual fatty degeneration the muscle fibres themselves 
show granules and oil droplets and disappearance of nuclei and normal 
markings; both conditions may be associated with primary anaemias, 
obesity, a cachetic state and senile atrophy. True degeneration may 
also accompany prolonged sepsis or severe infections, chronic hyper- 
trophy, dilatation, pericarditis, coronary disease or various chronic 
toxaemias. 

Symptoms. — Differential ante mortem diagnosis of fatty heart is sel- 
dom possible though the age of the patient, the habits, or the presence 
of obesity may be suggestive. On the other hand there are many sug- 
gestive symptoms as applying to chronic myocarditis in general. In the 
arteriosclerotic cases sudden attacks associated with pain, varying from 
a dull ache to extreme angina, may be associated with increased arterial 
tension, no doubt due to vaso-motor spasm. Such conditions are fre- 
quently transitory and the pain may be substituted by marked precor- 
dial oppression or sense of suffocation. In the more severe or terminal 
cases pulmonary edema is marked, cyanosis extreme and the patient dies 
suddenly or lapses into unconsciousness. Edema or general anasarca 
may be present but is often lacking. In all varieties the pulse may be 
markedly arrhythmic, unequal, and variable as to tension, and the heart 
sounds show abnormal accentuation and usually a foetal quality. The 
first sound at the apex is frequently absent or greatly diminished and 
under treatment a murmur may appear and the sound be partially 
re-established. Systolic murmurs, most commonly of the mitral and 
aortic orifice, are frequently observed and bradycardia or tachycardia 



MYOCARDITIS. 



219 



may be present or may alternate in the same patient. In the terminal 
stages of the disease one of the most characteristic features is the failure 
of response to such drugs as digitalis and oftentimes indeed to any Digitalis. 




Fig. 115. — Flabby heart, masked chronic myocarditi 
toris. Death from cardiac asthenia a few weeks latei 
by right border of heart and upper border of liver, sin 
cardial exudate. No fluid in pericardium. 



with atypical angina pec 

Note obtuse angle formed 

ilating Rotch's sign oi peri- 



drug or to rest, In the earlier stages however the same therapeutic 
measures, aside from the administration of digitalis, as are successful in 
ordinary valvular lesions may succeed here. The terminal symptoms 



j 



220 



MEDICAL DIAGNOSIS. 



Safeguard 

against 

error. 



A clinical 
curiosity. 






are merely those of extreme cardiac incompensation, frequently asso- 
ciated with angina pectoris or other evidences of vaso -motor spasm; 
attacks of severe dyspnoea, sometimes coming on during sleep, orthop- 
ncea, and if sudden death does not intervene the gradual development 
of general anasarca. An enormous number of these cases are overlooked 
and jail to receive the early treatment which might save much suffering 
and prolong life and usefulness. As before stated the vital error con- 
sists in the failure to demand the normal heart sounds in any case, 
too great stress being laid upon murmurs as indicating heart disease. 
So also actual dilatation may entirely escape observation.* A great 
number of these cases are encountered in connection with chronic alcohol- 
ism and indeed in those who are far from being either occasional or 
habitual drunkards. 

RUPTURE OF THE HEART.— This condition occurs only in 
persons having a degenerated heart muscle and in such may result from 
a fall, strain or other traumatism, such as is apparently insufficient 
to produce such an accident. Usually it occurs in the anterior wall 
of the left ventricle, rarely in the right and causes death instantly or 
within a few moments, preceded by severe pain, oppression and symp- 
toms of collapse. This condition is medico-legally important. 

ANEURISM OF THE HEART.— This rare condition may be 
saccular and associated with acute or chronic endocarditis or myo- 
carditis, or due to pericardial adhesion or gummata. As a clinical 
curiosity dissecting aneurism may be encountered. Death occurs 
usually from rupture and the disease cannot be diagnosticated ante 
mortem. 

FOREIGN BODIES IN THE HEART.— The organ is much 
more tolerant than is generally supposed; exploring needles, sewing 
needles, hat pins and even a knife or bullet may not cause death, 
indeed a small needle may be introduced with a minimum risk of a 
fatal result and it has even been suggested or actually employed as a 
therapeutic dernier ressort for cardiac stimulation. According to W. 
G. Thompson, war records show an astonishing exemption of the heart 
from bullet wounds though the statement is based upon the Civil war 
records which antedated the use of high penetration projectiles. 

NEW GROWTHS OF THE HEART.— New growths, tubercu- 



Remark- 
able toler- 
ance. 



* In a case observed not long since an old patient went to his death in an 
extremely high altitude upon the basis of expert opinion, though to the 
author's knowledge he had had severe recurrent incompensation with 
marked transient dilatation, due to myocarditis, for several years. 



ARTERIOSCLEROSIS. 



221 



losis, syphilis, various forms of sarcoma and carcinoma, and more 
rarely the myomata, lymphomata or fibromata may involve the heart. 
It may be the seat of abscess in pyemia, malignant endocarditis and 
acute myocarditis, or the seat of degenerative or cysticercus cysts. 

SITUS VISCERUM INVERSUS.— As a part of the general 
transposition of organs occasionally observed as a congenital phenom- 
enon we may find the heart upon the right side, the left ventricle 
being anterior and the apex in the usual relation to the nipple as in its Extremely 

t i rare. 

normal position. Such transposition is sometimes complete as regards 
the other organs, sometimes partial. Apparent transposition of the 
heart is common but usually proves to be due to a combination of 
unilateral pressure and lack of support.* As a temporary condition 
extreme degrees of displacement may be associated with pleural 
effusions. 

ARTERIO-SCLEROSIS.— Definition.— A chronic degenerative 
change involving especially the arterioles on the one hand and the 
larger blood vessels on the other, the two conditions being invariably 
associated. 

Morbid Anatomy. — The arterioles are the seat of arterio-capillary 
fibrosis, irrespective of the order of the degenerative changes, the 
endothelial and sub-endothelial tissues, the elastic layer and the 
media being involved, with resulting loss of elasticity, a les- 
sening of the calibre and increased peripheral resistance. In the 
larger arteries there is a cellular infiltration about the vasa vas- 
orum, involving the subintimal and medial layers, which is followed 
by degeneration and necrotic changes tending to weaken the arte- 
rial walls. Should an infiltration nodule undergo fatty and hyaline 
degeneration an atheromatous abscess is formed which may be con- 
verted into an ulcer by necrosis of the endothelial wall. When 
infiltrated by calcareous matter the nodules form the well known 
atheromatous plaques. This process may extend so far as to constitute 
a senile atheroma with its pipe-stem vessels, rigid and tortuous in outline, 
as seen in very aged personsor the victimsof premature senility. Phlebo- 
sclerosis is less common but may be marked. The aorta is the most 
frequent site of atheromatous changes and an arteriosclerotic process 
in the cerebral arteries is the most frequent cause of apoplexy, usually 
because of aneurismal dilatation. 

*In a case seen with Dr. B. J. Merrill, apparent complete displacement 

was due to almost complete tuberculous excavation of the right lung, with 
enormous hypertrophy of the left. 



MEDICAL DIAGNOSIS. 



Occupa- 
tion. 
Habits. 

Heredity. 
Sex. 

Age. 



Usual ci 
ditions. 



Important 
sign. 



Predispos- 
ing causes. 



Etiology. — Again one finds that Venus, Bacchus, Vulcan, Mammon, 
Mars or Minerva, may be held responsible, though such conditions may 
result from simple ageing forming one of the natural terminations of 
advanced life, and, on the other hand, may be distinctly hereditary, arterio- 
sclerosis being one of the most strikingly hereditary of all known condi- 
tions. Men are affected far more frequently than women and more 
or less change in the blood vessels must be expected in men who have 
reached the meridian of life and in many instances are seen in young 
men and even in children. These latter constitute cases of premature 
or precocious senility so far as the blood vessels are concerned. 

Symptoms. — Inspection. The superficial vessels are prominent 
(the temporals especially so), and oftentimes show a pulsation resembling 
that seen in aortic regurgitation but more vermiform. In marked 
cases the apex beat of the heart is displaced downward and to the 
left and the heaving beat of hypertrophy may be present. 

Palpation. — The finger recognizes readily the thickened artery of 
varying rigidity, which may be rolled under the finger as a distinct 
tube when the artery is shut off above and the nodular or plaque like 
irregularities may be noted when present. 

Auscultation. — The aortic second sound is sharply accentuated, and, 
as a rule, a systolic murmur in the aortic area simulating aortic sten- 
osis but due to the roughened intima may be present. (See also 
endocarditis.) 

General Symptoms. — Many curious transitory attacks may be 
experienced, the chief of which is vertigo, though transitory spas- 
modic seizures, monoplegias and hsemiplegias may also occur. Apo- 
plexy is of course always to be feared and if the coronary arteries are 
involved attacks of angina pectoris and intermittent and irregular 
pulse are most troublesome. As a general condition arterio -sclerosis 
leads to apoplexy, degeneration of the coronary vessels and myocar- 
ditis, and, to interstitial nephritis. The symptoms are so distinctly 
those of associated or dependent lesions as to need no extended 
description. In its atheromatous form it is the essential factor in the 
production of aneurism. 

ANGINA PECTORIS (dolor cordis, heart pang).— For purposes of 
convenience this complex is given a place by itself. // is nearly 
always a symptom of arterio-sclerosis, though marked degrees of arterial 
degeneration may exist and this symptom be absent. Persons sub- 
jected to severe mental strain and worry, who have reached or are 
nearing the meridian of life, are especially subject to attacks and men 



DISEASES OF THE ABDOMINAL ORGANS. 



223 



Acute gas- 
tric dilata- 
tion. 



who work with their hands may be comparatively free from it even 
though the arterial changes are marked. Attacks may be precipitated 
by violent emotion, such as fear, anger, grief, and, not infrequently, Excitants 
by sudden physical strain.* When patients are subject to attacks very 
slight influences may be adequate causes. So also after over -eating, 
indigestion, through fermentative changes and distension of the stomach 
may cause an attack of angina or close the earthly career of a victim 
of arterio -sclerosis or myocarditis. Sudden deaths of this kind are fre- 
quent in the experience of every coroner. 

Symptoms. — The essential symptoms are an intense pain in the region 
of the heart, and a sense of impending death. In typical cases the patient 
apprehensive, pallid and perhaps perspiring, and such may be 



Variable in 
severity, 
and seat. 



Various 
causes. 



afraid to speak or breathe while the attack persists. It is usually of 
short duration and is often characteristically relieved by such a drug as 
amyl nitrite. All these symptoms may, however, be greatly modified even 
in true angina, and the term cannot well be limited to the severer cases. 
Instances in which there is but moderate oppression may be encountered 
and the pain varies greatly in location, transmission and severity. 
It is usually associated with marked oppression; in extreme cases this 
may be described as crushing or vice like, shooting or aching; 
extension to the left shoulder and arm is common, and it may even be 
localized in the right upper chest though this is less frequently the case. 
Associated Lesions. — Though arterio-sclerosis is the chief cause 
angina often accompanies regurgitant lesions of the aortic valve, mitral 
stenosis, acute aortitis, chronic myocarditis and aneurism. In its 
milder forms it may hardly be differentiated from a pseudo-angina en- 
countered in victims of hysteria, neurasthenia and certain forms of 
dyspepsia or attacks related to the excessive use of alcohol and tobacco or 
sexual excess. 

DISEASES OF THE ABDOMINAL ORGANS. 

THE ABDOMEN (Abdo., I conceal).— Excepting the brain this 
is the most abscure region of the human body because of the shifting, 
air containing, obscurant intestinal coils, its inaccessibility to direct Obscure 
examination, and, the comparatively slight value of certain of the physical re -' on - 
methods so valuable in thoracic diseases. On the other hand the 

*In a case recently observed a series of attacks terminating in cerebral 
embolus and death followed a street car accident involving a sudden stop 
which threw the patient backward with such force as to snap the holding 
strap held in his left hand. 



J 



224 



MEDICAL DIAGNOSIS. 



Recent 
advance. 



Bounda- 
ries. 



Divisions. 



Contents. 



Land- 
marks. 



recent development of the laboratory side of the subject has been 
remarkable both as to extent and practical value. At the present 
time, while one must admit that positive diagnosis is often impossible, 
it is equally true that, too often, recourse is had to diagnosis by surgical 
exploration without any serious preliminary attempt to exhaust the 
more modern methods of purely medical diagnosis. 

Topography and Regional Divisions. — The spine, the lower costal 
margin, the iliac crest, Poupart's ligament and the pubic symphysis 
form the superficial boundaries of the abdomen and its cavity is roofed 
by the diaphragm which shelters and imparts respiratory movement to 
the liver, spleen, and, to a less degree, the kidneys and stomach. The 
upper limit of the cavity is indicated by a transverse line at the level 
of the base of the ensiform, the lower by the true pelvic brim. A 
vertical intersecting a horizontal line at the navel divides the abdomen 
into four quadrants. The upper right contains the liver, gall bladder, 
head of pancreas, kidney, the hepatic flexure, a portion of the transverse 
colon and the pylorus. The left upper, the left extremity of the liver, 
the spleen, splenic flexure, a part of the transverse colon, left kidney, 
the fundus of the stomach and most of the pancreas. The right lower 
contains the ascending colon, caecum and the vermiform appendix, the 
left lower the descending colon and the sigmoid flexure. The uterus 
and ovaries are anatomically pelvic and not abdominal and the lesser 
intestinal coils occupy the whole lower area. 

The anterior superior spine, iliac crest, pubic spine, lower ribs, 
costal margin and the ensiform are the chief bony landmarks. The 
tinea alba, the navel and the rectus muscles, divided into segments by 
the lineae transversa? and bounded externally by the lineae semilunares, 
are easily distinguishable in the abdomen of thin persons. The umbil- 
icus usually lies from an inch and a half to two inches above a line 
connecting the anterior superior iliac spines and is opposite the tip of 
the 3rd lumbar spine, and, the 10th and 12th ribs and the projection rep- 
resenting the gth cartilage are also important landmarks. The abdom- 
inal aorta bifurcates opposite the 4th lumbar vertebra three-fourths of 
an inch to the left of and below the navel, and the ilium and jejunum 
occupy chiefly the centre and lower portion of the cavity, the ilium 
largely on the left and jejunum on the right and below. The colon is 
less shifting and movable and ascends from the caecum upwards to the 
right, then (hepatic flexure) transversely, crossing above the umbilicus 
(transverse colon) under the left costal margin and (splenic flexure) 
downwards, inwards (descending colon and sigmoid flexure) to term 



DISEASES OF THE LIVER AND GALL-BLADDER. 



225 



inate in the rectum. The hepatic flexure lies under the arch of the 
liver, the splenic even higher under the left ribs. The transverse 
colon, sigmoid flexure and caecum are relatively superficial and the 
vermiform appendix lies with its base at a point representing the inter- 
section of the outer edge of the right rectus with a line drawn from 
the anterior superior iliac spine to the umbilicus {McBurney's point). 
It lies behind and to the inner side of the caecum with its apex down- 
ward, outward, inward or rarely upward. 

THE LIVER AND GALL-BLADDER.— The normal percussion 
outline of the liver is shown by the following table.* 



Middle Line. 



Mammillary 
Line. 



Midaxillary 
Line. 



Scapular 
Line. 



Upper 
limit. 



Lower 
limit. 



Deep 
dulness. 

Super- 
ficial 
dulness. 



Fourth 

space. 



Seventh 

space. 



Ninth 
space. 



Blends with 

heart 

dulness 

Hand's 
breadth 
below base of 
xiphoid. 



Sixth rib. 



Eighth rib. 



Tenth rib. 



Costal margin 
or somewhat 
above or be- 
low it. 



Tenth 



space 



Blends 

with 
kidney 
dulness. 



It should also be noted that the left lobe extends nearly to the left 
nipple, the interlobar notch lying in the median line. In children the 
liver lies lower, in old persons sometimes higher and in others lower 
than the position given. 

The gall-bladder lies just within the projection of the 9th costal 
cartilage near the outer edge of the right rectus. 

The spleen lies in the left upper quadrant just outside the spine 
in close relation to the diaphragm above, the left kidney, posteriorly, 
and the colon, stomach and small intestines below. It is oval, flat- 
tened and in length from three to five inches and it lies parallel to and 
within the area of the 9th, 10th and nth ribs, its anterior margin reach- 
ing a line dropped from the sterno-clavicular joint to the point of the 
nth rib. In two-thirds of its surface it is parietal. 

The Kidneys. — These lie in apposition to the posterior wall, being 
in contact above with the liver on the right side and the spleen on the 
left and move with respiration. The right is slightly lower than the left 



* Hutchinson and Rainy. 
IS 



Clinical Methods." 



226 



MEDICAL DIAGNOSIS. 



Removal 
of fecal 
masses. 



Rela 
tion 



Diverting 
attention. 



Use of 
hands. 



Important 
data. 



and each lies two-thirds within the mid-clavicular line, the lower border 
of the right being one inch, that of the left i£ inches above the navel. 
Posteriorly, they lie within a parallelogram represented by two verticals 
drawn respectively one inch and two and three-fourths inches from the 
spinous process, and two horizontals representing the nth dorsal 
and 3rd lumbar spines; thus about one-third of their surface is covered 
by the nth and 12th ribs and their lower extremity lies from an inch to 
an inch and a half above the crest of the ilium. 

TECHNIQUE OF ABDOMINAL EXAMINATIONS.— All varie- 
ties or subdivisions of clinical methods are applicable to this region. 
The -first step when time permits consists in the administration of a 
cathartic, a procedure, however, by no means always employed nor 
indeed necessary, for its chief purpose is to remove masses of fecal 
matter which might be mistaken for abdominal growths and in some 
instances it has the positive disadvantage of producing gaseous disten- 
sion and prolonged peristaltic activity which may obscure the findings. 

The attitude of the patient is most important. The head and shoul- 
ders, particularly the former, should be well raised, the feet firmly 
placed, and the patient himself be in a secure, easy and unconstrained, 
dorsal posture. To secure muscular relaxation of the walls it is usu- 
ally recommended that the knees should be drawn up, but often, better 
relaxation may be had with the legs extended or but slightly flexed. The 
breathing should be easy and natural with the mouth open and the 
patient's attention should be diverted by conversation and inquiry relat- 
ing to other phases of the case. The palpating hands should be warm, 
the light should be adequate and its source behind the patient, and no 
clothing or other covering embarrass the examiner. The flat of the 
palm and fingers, not the tips, should be used and tender areas should 
not be immediately approached; nor does the discovery of one justify 
repeated and purposeless punching and poking. In palpating movable 
organs or growths respiratory movement should be met directly by the 
tips of the fingers at right angles to the free margin, the hand being 
firmly but gradually depressed in deep expiration and allowed to rise 
laggingly and shift slightly upwards to meet the descending border in 
inspiration. If the hand moves the organ or growth under examination 
the opposite palpating hand should be almost motionless as the other 
brings the organ or tumor to it. After tolerance is established the finger 
tips may be used much more freely for the determination of consistence 
and outline. If excessive pain or tenderness be encountered one should 
note whether it is superficial and felt on light pressure, or only on deep 






DISEASES OF THE ABDOMINAL ORGANS — EXAMINATION. 



227 



pressure and whether it is distinctly localized or diffuse. Malingering 
or hysterical patients can often be misled or diverted by conversation 
or by attracting their attention to some special region which is being 
explored by the one hand, while the supposed tender point is palpated 
by the other. In some cases nothing less than general anoesthesia 
suffices. The dorsal posture is the best for general purposes but the 
lateral is often of value in the palpation of the spleen or kidneys or for 
the purpose of " spilling " the intestinal contents of a large bellied person 
to render more accessible the lateral region under examination. (A 
special procedure (dipping) is referred to under ascites, page 12.) 
In many instances the patient may with advantage be placed upon the 
hands and knees or in the knee chest position to bring a growth forward 
against a thin and relaxed abdominal wall, the procedure being seldom 
successful otherwise save under anaesthesia. Finally, all portions oj 
the abdomen should be thoroughly examined not forgetting the hernial 
openings. 

THE PHYSICAL EXAMINATION AND ITS SPECIAL AP- 
PLICATION. — Points to be determined. — (a). The condition of the 
organ under observation (size, outline, condition of surface, mobility, ten- 
derness), (b). The presence of swelling or tumors (intra- or extra-ab- 
dominal, size, outline, surface, mobility, tenderness, associated symptoms). 
(c). Presence of pain or tenderness (true or false, intensity and character, 
exact location, superficial or deep and the effect of pressure). Pain 
increased on pressure ordinarily suggests inflammation. 

General Inspection. — The nutrition, musculature and abdominal 
outline are first noted. General distension may be due to tympanites, 
ascites, chronic tuberculous peritonitis, great dilatation of the stomach 
or colon, pregnancy or ovarian tumor. Localized distension or swelling 
to hysteria (phantom tumor), ventral hernia, abscess, intestinal obstruc- 
tion, new growths, dilatation or displacement of the stomach. 

General retraction may indicate extreme emaciation, carcinoma of 
the stomach and especially of the cardia, lead poisoning, meningitis, 
chronic diarrhoea or dysentery. The skin may show an eruption of the 
acute exanthemata, syphilis or skin diseases, areas of pigmentation 
atrophy and the various hues and discolorations already discussed 
under the "outward signs of disease," or the white or bluish striae 
indicating present or past distension by tumor, pregnancy, ascites 
or excessive fat; the linea nigra or dark median line may indicate a 
pregnancy, the superficial veins may be enlarged in the ease of portal 
or vena caval obstruction, and point tb hepatic cirrhosis, tumors or 



Useful 

device. 



Varied 
postures. 



Outline. 



228 



MEDICAL DIAGNOSIS. 



Veins. 



How 

increased. 



Variability. 



" Ladder 
pattern." 



Cooing. 



Technique. 
Mobility. 



prolonged ascites in the former, or the pressure of abdominal 
growths or thrombosis in the latter. If the superior cava be obstructed 
the direction of the blood flow in the large superficial veins (readily 
determined by emptying one and watching its refilling) will be downward, 
in other conditions it is upward. If the visible distension is most marked 
in the pubic surface-segment, obstruction below the liver is suggested. 
Aortic obstruction as indicated by enlargement and prominence of the 
epigastric and internal mammary arteries is a clinical curiosity.* 

Visible Peristalsis. — In the presence of emaciation and a thin and 
relaxed abdominal wall peristaltic movements may be noticeable and 
are readily made more pronounced by snapping the surface with the 
finger nail or wet towel, splashing upon it a little ether or applying 
the faradic current. Normally the movements are deliberate and wave- 
like and occur usually without borborygmi, but in acute obstruction they 
may seem to be fiercely attacking the stenosed region. Normal 
stomach peristalsis runs from left to right; that of the transverse colon 
from right to left, a point slightly diminished in value because of the 
rare reversed peristalsis in marked pyloric obstruction. In relation to 
obstruction of the bowel, acute or chronic, the sign is of distinct value, 
one of its commonest forms, the "ladder pattern" peristalsis, running 
from the ilio-caecal valve region towards mid-abdomen. f In sigmoid 
obstruction there is increased violent peristalsis along the course of 
the colon and a cooing or loud rumbling associated with the disap- 
pearance of distension which at times sharply localizes the point of 
constriction. One of the commonest causes of increased visible peristalsis 
is stenotic dilatation of the stomach. 

THE LIVER. — Inspection sometimes shows a lower border shadow 
descending with deep inspiration. The normal percussion outlines have 
already been given, (see page 225) . Auscultation is of no value save in the 
detection of peritoneal friction in inflammatory lesions or abscess and 
the most useful physical method is palpation. 

Palpation. — The normal liver can often be palpated easily if the 
wall be relaxed and the liver edge met by the fingers rising with 
the wall in deep inspiration. Directness and immediateness of move- 
ment are characteristic of the liver as compared with that of the mova- 

* See congenital heart lesions. 

t In two such instances observed by the author marked obstruction due 
to appendicitis existed for a period of 30 years, the diameter of the tube 
having been reduced to that of a crow quill. In one case the recurrent 
attacks had been so violent as to have led to an operation for gall stones, 
the pain being to some extent referred to the hepatic region. 



DISEASES OF THE GALL-BLADDER. 



229 



Pulsation. 



Valuable 
method. 



ble kidney or a pyloric growth and is absent only when adhesions exist Fixation 
or there is decided limitation or complete absence of diaphragmatic 
descent. Any decided resistance in the liver edge as palpated indicates 
a morbid change in the hepatic tissue, such as cirrhosis, chronic conges- 
tion or tumors. Rarely, and more often in children, the liver pulsates Consist 
directly and expansively from tricuspid regurgitation and, yet more often, 
there appears a transmitted pulsation due to a dilated right ventricle. 

Percussion. — As regards percussion it should be said that a reduced 
area is especially significant if it involves the region of the left lobe as this 
is earliest affected in atrophic cirrhosis. Diminution of the upper (thor- 
acic) area may arise from shrinkage of the liver but is more commonly 
only apparent and due to emphysema of the lung or, rarely, diaphrag- 
matic hernia. This area varies with deep inspiration and expiration not 
only by reason of the descent of the organ but because of the descent of 
the lung border. Auscultatory percussion will be found valuable par- 
ticularly in connection with the left lobe or in deciding whether a tumor 
is hepatic in origin or attachment. The stethoscope should be placed 
over the thoracic area of superficial hepatic dulness while the finger taps 
the surface in radiating lines until the decided change of note indicates 
that hepatic tissue has been passed. Attached tumors will usually yield 
the hepatic note under these conditions. One of the commonest errors of 
the tyro in the examination of the liver or spleen is that of beginning 
palpation too high, great enlargement of either organs being frequently 
overlooked. 

Conclusions. — Upward extension of dulness in the hepatic area sug- 
gests enlargement of the liver, pleural effusion or adhesions, pulmonary 
consolidation, hepatic or subphrenic abscess. Diminution of upper 
boundaries indicates hepatic atrophy, asthma, emphysema, pneu- 
mothorax, gaseous distension of a subphrenic abscess, hepatic ptosis 
and rarely, massive pericardial effusion or cardiac dilatation. General 
enlargement may be due to passive congestion of cardiac origin, the 
commonest cause, hypertrophic cirrhosis, leukaemia, fatty liver, amyloid 
disease, syphilis, cancer, gumma, abscess, pyemia. General shrinkage 
suggests atrophic cirrhosis, the commonest cause, with acute yellow- 
atrophy as a clinical curiosity. 

Irregularities in Outline.— Such may be due to congenital defects, 
various enlargements and displacements, atrophic cirrhosis and indeed 
practically all of the conditions noted in a preceding paragraph. Oi 
special significance are the nodular irregularities (often showing 
crateriform depressions) associated with secondary carcinoma, and 



Modified 

percussion 

areas 



w 



230 



MEDICAL DIAGNOSIS. 



Nodules. 



Hydatid 
thrill. 



Caution. 



Mobility. 



Crepitation 
rare. 



Mobility. 



Proper 
attitude. 



tertiary syphilis. Glissonian cirrhosis may produce marked shrinkage 
and deformity whereas the tiny granular elevations of atrophic cirrhosis 
can be palpated only under exceptional conditions, as when the wall 
is thin and lax, though the sharp resistant edge in an advanced lesion 
is striking. Fluctuating swellings or tumors modifying the outline 
are usually due to a distended gall-bladder, abscess or hydatid cyst; 
the last yielding a peculiarly exquisite thrill, echoing the percussion 
stroke. It should be remembered that an enlarged liver, easily palpable, 
with a smooth hard surface, suggests amyloid disease, passive congestion 
and fatty liver. Roughening suggests cirrhosis or tuberculosis; nodulation, 
carcinoma and syphilis. Finally it will be noted that mere increase 
or diminution in the hepatic area yields no information as to the actual 
size of the organ unless checked carefully by an examination of the 
contiguous structures. 

THE GALL-BLADDER. —Palpable only when distended it may then 
form a pear-shaped tumor,* smooth and elastic, anchored above but freely 
movable from side to side, and in the absence of adhesions, rising and 
falling in respiratory rhythm with the liver itself. Rarely, a palpable 
crepitation may be obtained if gall stones are present or it may be 
nodular from malignant disease. In long standing cholecystitis it may 
undergo atrophy. 

THE SPLEEN. — A greatly enlarged spleen and more rarely one 
scarcely more than palpable may be seen to move with the respiration; 
furthermore, in any case of splenomegaly, a marked prominence of at least 
the left upper quadrant is produced. f As in the case of the liver, 
auscultation may reveal friction sounds in the presence of perisplenitis, 
or the organ may be anchored by adhesion, but it is ordinarily freely 
and directly movable with respiration, and palpation is the only method 
yielding important results. The position of the patient should be right 
lateral if minor enlargements are to be noted, as in typhoid fever or other 
acute infections, and the right hand should make pressure posteriorly 
while the left makes palpation. Abdominal distension defeats pal- 
pation save in great enlargement and the normal spleen is not palpable. 

* These tumors in rare instances attain an enormous size, Albuan Doran 
having recently reported one simulating ovarian cyst. (British Medical 
Journal, June 17, 1905.) 

t In a case recently shown by the author to the Minnesota State Society 
a leukaemic spleen filled the entire abdomen, actually reaching the right 
anterior superior spine of the ilium, and strange to say the patient showed 
no impairment of health, change in color, or malnutrition and declined to 
cease work or take treatment. 



KSfc 



DISEASES OF THE SPLEEN. KIDNEYS. 



23I 



If greatly enlarged the dorsal position is to be preferred and the condition 
can hardly be overlooked, unless with a tense wall the careless or hurried 
examiner fails to get below the actual border or to distinguish between 
muscular resistance on the one side and the splenic mass on the other. 
In these cases the chief notch in the anterior border is sharply defined 
and quite distinctive. Students at first palpate too deeply to recognize 
minor enlargement. In all cases where doubt arises as to the nature 
of a large tumor in the splenic area it should be remembered that a splenic 
growth or tumor is superficial, that its dulness is marked and can be 
carried directly back to its normal area behind the gth, 10th and nth 
ribs, that it ordinarily moves directly with respiration and that if the 
colon be inflated splenic tumor dulness is not impaired. On the con- 
trary, large renal tumors extend more deeply, are relatively fixed or 
immovable, are likely to be reniform or nodular and are crossed by an 
area of resonance if the colon be distended with air. As in the case of 
the liver a downward displacement of the diaphragm may produce 
an apparent increase in the lower splenic area just as an emphysematous 
lung or a pneumothorax may cause an apparent diminution in its upper 
percussion area. 

Causes of Enlargement. — Excessive chronic enlargement is most 
frequently due to leukaemia, splenic anaemia or chronic malaria; lesser 
degrees may be met with in cirrhosis of the liver, rickets, pernicious 
anaemia, passive congestion, or actual portal obstruction. Acute 
enlargement is most often encountered in septicaemia, malarial fever, 
typhoid and typhus, erysipelas, acute miliary tuberculosis, tuberculous 
peritonitis, cerebro-spinal meningitis, smallpox, diphtheria, scarlet 
fever, relapsing fever, infarct, plague and certain other tropical diseases. 

Enlargement of the spleen is nearly always uniform, abscess being an 
occasional, and hydatids or carcinoma an excessively rare cause of irreg- 
ular outline. 

KIDNEYS. — The normal kidney yields no results to inspection or 
auscultation and indefinite ones to percussion. When enlarged by dis- 
ease it may be evident in the anterior lumbar region and be readily 
accessible to percussion and palpation and, bulging may also be mani- 
fest posteriorly. The sarcomata in children, and cystic, tuberculous or 
hydronephrotic kidneys in the adult, are the most frequent causes of 
enlargement. 

Palpation. — The dorsal and scmidorsal postures arc the host, and. 
in the latter, relaxation is assisted by supporting the shoulders and 
buttocks and bringing the hand and arm of the side under examination 



Source of 
error. 



Important 
data. 



Low 

diaphragm. 



Posture. 



„ 



232 



MEDICAL DIAGNOSIS. 



Degrees o 

mobility. 



Source of 
error. 



Peculiar 
form. 



Lagging. 



Technique, obliquely downward and forward across the abdomen. One hand 
of the examiner makes pressure over the floating ribs or just below them 
posteriorly, while the other is pressed deeply downward and slightly 
upward outside the rectus border on a level with the umbilicus. If 
the kidney is movable it will slip downward in deep inspiration so as to 
be grasped between the tips of the fingers of the two hands. The 
normal kidney yields to palpation only its lower border and this only 
under favorable conditions. Any greater degree of mobility constitutes 
movable kidney. If the organ is so movable and displaceable as to 
suggest a mesonephron it is a floating kidney and such are sometimes 
overlooked because at the moment they occupy some distant portion of 
the abdomen, being frequently found low down in the region of the 
pelvic brim or displaced across the median line.* 

Percussion. — The semidorsal position is best adapted for percus- 
sion which is usually superfluous, uncertain and often misleading. 
Occasionally displacement is suggested by the substitution of tympany 
for normal dulness or an unusual extension of the latter may point to 
diseased conditions. 

Characteristic Features. — The reniform shape and peculiar con- 
sistence of the kidney are readily recognized unless the organ be markedly 
inflamed or the seat of a new growth. Under these conditions the 
tumor is readily palpable, relatively or absolutely fixed, regular or irregu- 
lar, smooth or nodulated, according to the nature of the morbid process. 
If the organ be merely movable as is so often the case, its maximum dis- 
placement occurs near the end of full inspiration, a fact readily explained 
by its relation to the diaphragm and the directly movable spleen and 
liver. Furthermore, such displaced kidneys are replaceable into the 
flank or normal kidney position and in fixed renal tumors inflation of 
the colon establishes a band of resonance crossing or wholly obscuring 
the percussion dulness anteriorly. Secondary abscess in the renal region 
is not uncommon as a sequence of neglected appendiceal abscess, 
empyema, subdiaphragmatic abscess, caries of the vertebra, etc., and 
one must consider the globular elastic or possibly fluctuating tumors 
of hydro- or pyonephrosis, the irregular cystic tumors, the denser more 
nodular malignant growths and the bogginess or induration of the peri- 
nephritic suppurations which tend posteriorly rather than anteriorly, 

* It is sometimes advised that examination should be made with the 
patient leaning forward in the standing posture with the elbows or hands 
supported on a chair or table. The author has never found this procedure 
of special value except with extraordinarily lax abdomens or when the kid- 
ney was greatly enlarged. 



DISEASES OF THE STOMACH. 



2 31 



in contradistinction to tumors of the kidney itself. Chemic and 
microscopic examination of the urine, careful consideration of primary 
factors and the use of the aspirating needle assist diagnosis. 

THE STOMACH.— General Considerations.— Despite modern 
advance there is a remarkable lack of positive knowledge in regard to 
the capacity, dimensions and normal position of the human stomach, 
and, indeed, of the vagaries of its secretory activities. The stomach of 
the newborn baby has a capacity of but one or one and a half ounces, 
yet in from six to eight years this is increased to one quart and the 
capacity of the adult stomach varies from one to two quarts. Five- 
sixths of the stomach lies to the left of the median line; the transverse 
measurement varies from twelve to sixteen inches; the depth from 
above downward is but six inches and the distance between the pyloric and 
cardiac orifice but one and a half inches. The fundus lies in the left cup 
of the diaphragm and the upper limit of percussion resonance normally 
extends to the fifth left interspace in the parasternal and midclavicular 
lines, while the lower runs from one to two inches above the navel. 
The pylorus should lie midway between the right sternal and parasternal 
lines at the level of the xiphoid, the cardiac orifice lying about an inch 
and a half to the left, opposite the nth dorsal vertebrum. Absolute lines 
cannot be drawn for the delimination of an organ so distensible and 
freely movable. In general it may be said that a stomach whose lower 
border reaches the navel is abnormal, either in size or position. 

PHYSICAL EXAMINATION.— Inspection.— This yields valu- 
able results more often than is generally supposed, and, especially in 
cases with thin, relaxed, abdominal walls, the outline of a distended 
stomach may be clearly defined. Growths, especially of the pylorus, 
are often seen to move with respiration and normal (left to right) or 
very rarely reversed (right to left) peristalsis may be present, often 
affording valuable corroborative evidence of pyloric obstruction, the 
gastric waves being large and deliberate and taking from \ to i minute 
to pass across the field. In the congenital pyloric obstructions of chil- 
dren the tumor is often readily seen. 

Fluoroscopy and Transillumination. — By giving the patient 
massive doses of bismuth subnitrate (20 gms.) mixed with porridge or 
some similar food, fluoroscopic or skiagraphic evidence may be ob 
tained, while occasionally Einhorn's method of transillumination may 
greatly assist inspection. The gastrodiapinuw is merely a moderately 
rigid bougie or soft tube carrying an electric Light. The patient drinks 
two glasses or more of water, after which the instrument is introduced 



Valuable 

aids. 



Lack of 
data. 



Capacity. 



Position 
and dimen- 
sions 



Fundus. 



Cardia and 
pylorus. 



Valuable. 

Outline. 
Growths. 

Peristalsis. 



Bismuth. 



Gastrodi- 
aphanj . 



1 



234 



MEDICAL DIAGNOSIS. 



Pathologic. 






Normal. and the electric circuit completed. In a normal stomach an illuminated 
zone appears in the region of the left lower segment of the normal 
J fundus and extends about to the lower margin of the left lung. It is 
triangular in form, the apex being downward and slightly above the 
umbilicus. It naturally follows that in gastroptosis or dilated stomach 
(gastrectasia) the illuminated area is lower and larger. The infor- 
mation gained through inflation of the stomach is usually so much 
greater that the method is seldom required. 

Palpation. — This is chiefly used to determine three points: (i). The 
presence of a tumor. (2). Localized tenderness. (3). Succussion. The 
palpable tumors of the stomach most often involve the pylorus and lie 
to the right of the median line between the margin of the ribs above, 
and the navel below. Areas of thickening, often plaque like in feel may 

Old ulcers, indicate an old ulcer base and though adhesions frequently occur, 
anchoring the stomach to adjacent organs and greatly complicating 
and obscuring diagnosis, ordinarily such growths move freely and 
indeed oftentimes are so widely removed from the usual site as to sug- 
gest growths of distant organs. Their movement and position in con- 
nection with inflation then becomes of especial importance. In very thin 
flabby abdomens one must be on his guard against mistaking other struc- 
tures, perhaps normal, for gastric growths. Intermittent stomach rigid- 
ity over the fundus may be encountered in cases of pyloric stenosis and 
through relaxed thin walls or in cases of enteroptosis the pylorus may be 
directly palpated and felt to harden and relax with an associated "squirt- 
ing" sensation (spritz gerausch) and, if a soft tube be used the point may 
be distinctly felt as it is coaxed along the lower border to the pylorus. 
Succussion is obtained by placing one hand over the lower left ribs 
posteriorly while making sharp dipping movements anteriorly. Any 
splashing sound suggests dilatation or gastroptosis if it occurs more 
than 7 hours after a meal. The value of this' sign has been greatly 
overestimated and is practically limited to its occurrence before break- 
fast or on a fasting stomach. In general it merely indicates slight 
motor insufficiency, or, if it be obtained within narrower limits but by 
very gentle tapping it strongly suggests gastric atony* Finally, dila- 
tation of the stomach may, though rarely, occur without superficial splash- 
ing and the sign is undoubtedly in some degree dependent upon the con- 
dition of the abdominal wall itself. 

Percussion. — Ordinary percussion is of little use and need not be 

discussed. It was formerly the custom to introduce a pint or more of 

* Sahli distinguishes between "deep splashing" and "superficial splashing." 



Useful 
method 



Overesti- 
mated sign 



DISEASES OF THE STOMACH. 



235 



water and percuss the dull area produced, but both the boundary and 
the muscle tone are better established by inflation. 

Auscultatory percussion is distinctly useful, particularly if pre- 
ceded by inflation. Normal gastric tympany is represented by the seg- 
ment of a circle, being limited above by hepatic dulness, but includes 
Traube's space and has a curved border below which should not reach 
the navel. Thus contraction of the left lobe of the liver, shrinkage 
of the left lung and marked distension of the stomach tend to enlarge 
it. By careful auscultatory percussion the upper right and left limits 
may be somewhat extended, though the change of note due to the lung 
and left hepatic lobe will be distinctly marked. 

Technique. — The bell of the stethoscope is placed just below and to 
the left of the ensiform cartilage and percussion is carried from it in radi- 
ating lines, in accordance with the boundaries outlined above, either 
from the stethoscope outward until the note changes, or, from the 
surrounding negative areas towards that of gastric resonance. It is 
well to shift the position of the stethoscope and repeat the percussion 
in order to check results. So also in the case of a growth, if the stetho- 
scope be placed over it and a similar method employed, one may often 
determine its connection with the stomach. An elaborate description 
of the tones is unnecessary as the veriest tyro can distinguish the changed 
note that indicates that the stomach border has been passed.* 

Auscultation. — This almost valueless method finds its only use in the 
detection of esophageal "swallowing sounds," the succussion sound 
already referred to, and the sizzling or fizzing of active fermentation 
and the test for hour glass (bilocular) stomach. 

Turck's Gyromele. — This interesting instrument lends itself to 
inspection, palpation and auscultation and consists of a flexible piece of 
steel such as a piano wire inclosed within a rubber tube and bearing 
a soft sponge. Being introduced into the stomach it is attached to a 
little hand instrument which causes rapid revolutions and will distinctly 
show the sponge as it passes along the lower gastric border. Its inventor 
uses it not only for diagnostic but for therapeutic purposes. 

Inflation of the Stomach. — Methods. (1). The oldest and simplest 
involves the administration of one dram of sodium bicarbonate in a 
wine glass full of water, followed promptly by an equal amount of tartaric 
acid similarly dissolved. Theoretically it is open to the objection that 



Best 

method. 



Areas. 



Slight 
value. 



Often 

useful. 



Old 
method. 



*The note is uniform in quality and pitch so long as the stomach is per- 
cussed, though intensity depends upon the distance of the stroke from the 
stethoscope. 



J 



236 



MEDICAL DIAGNOSIS. 



Best 

method. 



Caution. 



Tumors. 



Ectasia 
and ptosis. 



Simple 
require- 
ments. 



serious danger may result, especially in ulcer, from overdistension; 
practically this danger is slight yet the method is decidedly inferior to 
the following one. (2). After introducing the stomach tube, air is pumped 
into the stomach with a Davidson's syringe or if the patient be tolerant 
and the physician courageous the inflation may be accomplished by 
blowing into the tube. As the degree of inflation is wholly under 
control in this matter the procedure has almost wholly superceded the 
older one. The distension should not be great and the same contra- 
indications govern it as in the use of the stomach tube itself.* 

Inflation brings into prominence tumors of the anterior wall and 
obscures those of the posterior wall. In general, gastric growths are 
cylindrical at the pylorus, broad and flat on the fundus. 

Interpretation of Outline.— The normal boundaries have already 
been given; if abnormal, one should carefully note whether there is 
merely a normal or approximately normal area in an abnormal position 
(gastroptosis) , whether there is both abnormal position and increased 
area (gastroptosis with ectasia), or finally, whether there is general 
enlargement without marked displacement (simple dilatation). 

THE STOMACH TUBE AND ITS USES.— One should use a 
soft rubber tube carrying ample fenestrations at its extremity and a 
large terminal perforation. It should be surmounted by a glass 
funnel and some physicians introduce, a few inches below, a glass 
tube as an indicator. According to the author's experience the simpler 
the stomach tube the better are the results and the elaborate and 
complicated special tubes are unnecessary. 

Contraindications. — Under certain conditions the introduction of the 
tube is unjustifiable and dangerous, and it is always necessary to bal- 
ance the value of the result to be obtained and the possible danger 
experienced, f The following conditions usually forbid the use of 
the tube in those not habituated to its use. (a). Extreme weakness 
and exhaustion from whatever cause, (b). Advanced myocarditis, (c). 
Recent hcematemesis or tarry stools, (d). Advanced arteriosclerosis or 
past cerebral hemorrhage, (e). Pregnancy, (f). Aortic aneurism, (g). 
Terminal pulmonary tuberculosis especially if haemoptysis has occurred, 
(h) . High grades of emphysema. Furthermore, in elderly persons of apo- 
plectic build and tendency the first passage of the tube usually involves 

* Coincident distension of the colon by injections of water is employed 
by some clinicians. 

f That this is not imaginary was shown not long since in a case observed 
by the author in which a large soft tube passed directly through the base of 
a carcinomatous ulcer. 



^ 



EXAMINATION OF GASTRIC CONTENTS. 



237 



an amount of straining and congestion that is extremely dangerous. 
These restrictions need only apply to hemorrhagic cases and aneurism in 
those habituated to the use oj the tube. 

Technique of Introduction. — The patient should be reassured and 
told to obey orders absolutely, swallowing when told to do so and breath- 
ing deeply through the nose. Sharp commands are often successful 
and effective in shutting off nervous gagging or retching or attempts 
to pull out the tube, which should be warmed by placing it in hot water, 
held like a pen and introduced promptly and firmly without haste and 
without regard to temporary obstruction. The patient may be asked 
to swallow as it reaches the pharynx and there need be little fear that 
it will enter the larynx; if it does, the fact is at once evident, the tube is 
removed and no harm done. No considerable force is at any time 
necessary nor should it be employed. The depth to which it should 
normally be passed is from 16 to 22 inches from the teeth and the 
average distance is usually indicated upon the tube. In ectasia it will 
need to be more deeply introduced and the fact is diagnostically sug- 
gestive. The patient's head should be slightly forward, the mouth 
open, the tongue in, and neither in the introduction oj a stomach lube 
nor in that oj an esophageal bougie is there the slightest reason jor intro- 
ducing the finger into the patient's mouth, a procedure which increases 
gagging and distress and often involves a bitten digit. To obtain the 
contents, the patient is asked to take a deep breath and strain as at stool, 
while leaning sharply forward. This movement may be assisted by 
firm pressure over the region of the navel made either by the patient or the 
operator. In some cases it may be necessary to attach a syringe bulb 
or Politzer's bag to the tube and make suction.* From time to time 
a tube may be blocked and the bulb may be used to force in jets of air 
or, the obstruction may disappear if the tube be slightly withdrawn 
and reintroduced; this latter procedure being often necessary in any 
event. The first attempts to introduce a stomach tube are usually 
associated with more or less violent retching and straining and are 
greatly dreaded by the patients, but they may be assured that after 
three or four introductions the discomfort will be slight. 

EXAMINATION OF GASTRIC CONTENTS.— Aside from the 
methods described under examination of the abdomen, our knowledge 
of gastric ailments depends upon a consideration of the case history in 



Important 
sugges- 
tions. 



Keep fin- 
gers out of 
mouth. 



Expression 
of contents. 



Tube 

blocking. 



Habitua- 
tion rapid. 



*Such a bulb can readily be fitted with a glass tube that accurately 611* 
the calibre of the stomach tube and the device is better than the use of . 
compression bulb on the tube itself. 



i 



2 3 8 



MEDICAL DIAGNOSIS. 



Physiol- 
ogy. 



Applica- 
tion. 



Effect of 
diet. 



connection with a chemical examination of the stomach contents taken 
after a test meal. After ingestion of any ordinary articles of food there 
follows a period of rising acidity. The hydrochloric acid combines 
promptly with the proteids and alkaline bases leaving no free acids to 
inhibit fermentation by bacteria, hence for from 15 to 40 minutes after 
a meal one would find hydrochloric acid abundant in combination, 
but absent as a free acid, while starch transformation would progress 
unhindered and lactic acid would appear because of fermentation or 
introduction with the food. A second period follows during which the 
affinities of the proteids are satisfied, free hydrochloric acid appears 
and fermentation ceases. After certain test meals, this period should be 
attained an hour after the meal is ingested and one thus has a definite 
normal by which abnormal variations may be measured. This second 
period is followed in two hours or more by a third characterized by a 
fall in the acidity. An excess 0} proteids requires much acid for com- 
bination and means in all cases a delay in the appearance of free hydro- 
chloric acid; an excess of carbohydrates acts in the opposite way, their 
acid affinities being promptly satisfied. 

Points to be Determined. — Primarily one seeks for free or com- 
bined hydrochloric acid, the latter representing a loose chemical com- 
bination with alkali-albumin and undergoing progressive transformation 
by means of an acid and the action of the digestive ferments which 
results in the production of (1). Acid albumin. (2). Prolo- or hetero- 
albumoses. (3). Deutero-albumoses and finally, peptones. 

Certain Standard Test Meals are here given but it should be 
remembered that any meal will give results if its constitution be known 
and that finical exactitude is not essential. 

Ewald's Test Breakfast. — One or two slices of stale bread or one 
or two baker's rolls and from 300 to 400 c.c. (8-12 oz.) of weak tea or 
water. This represents 35-70 gms. (1 to 2 oz.) of solid, but the exact 
amount is not material. It should be taken in the morning and retained 
for not less than one or more than one and a half hours. 

Boas' Test Breakfast. — One tablespoonful of oatmeal is added to 
one quart of water and boiled down to one pint. It should be taken 
plain save for a little salt and removed in not less than one nor more 
than one and a half hours. This breakfast is especially valuable in 
cases of suspected cancer of the stomach as it introduces no lactic acid, 
the determination of which is so important in this disease. In such 
cases the stomach should be washed out the night before or in the morning 
an hour before the meal is taken; in fact Ewald's breakfast seldom causes 



DISEASES OF THE STOMACH. 



2 39 



any confusion, lactic acid not being introduced in sufficient quantity to 
produce the ordinary clinical reaction suggesting carcinoma. 

The Test Dinner of Von Leube and Riegel. — 400 c.c. (12-14 
oz.) of soup; 50 gms. (2 oz.) (or two ordinary slices) of wheat bread; 
100 to 200 gms. (3-6 oz.) finely divided beefsteak and 200 c.c. 
(6 oz.) of water constitute the meal. It is removed about 4 hours 
later. 

The Macroscopic Appearance of the Stomach Contents. — One 
hour after an Ewald test breakfast the appearance should be that of thin 
porridge, the bread in particles rather than distinct fragments and little 
or no mucus present. The filtrate should be clear or thin yellow and of 
slight odor. Anacidity or marked hypoacidity is indicated by unchanged 
or slightly modified bread fragments, slow filtration and a musty odor. 
Hyperacidity by greater fluidity, foamy surface, stale, acid odor and 
rapid deposit of sediment. In catarrhal gastritis the thick slimy content 
with evidence of subacidity is characteristic and in hyperchlorhydria 
with excessive motility, the stomach may be entirely empty. 

Other constituents are discussed under "vomitus,"p 249, and other 
headings. 

QUALITATIVE TESTS.— The following procedure is simple and 
convenient: — (a). Test filtrate with congo-red paper or solution (congo-red 
1, distilled water 100), or add 1 or 2 drops of an alcoholic solution 
of di-amido-azo-benzol (.5%) ; free acid is indicated by blue discolor- 
ation with the former, or red with the latter reagent.* 

(b). In the absence of HCl, lactic acid should be sought by placing 
in the test-tube 2 drops of carbolic acid, 6 drops of neutral tincture of 
ferric chloride and adding water until a deep but clear amethyst color appears. 
The filtrate is then added* drop by drop and if lactic acid be present a clear 
thin yellow reaction appears; no attention need be paid to doubtful 
reactions. Lactic acid is always abnormal if appearing one hour or 
more after a test breakfast. f (c). Acetic and butyric acids are 
revealed by the odor of vinegar and rancid butter produced upon 
heating. Butyric acid appears as small oily drops of characteristic 



Normal. 



Abnormal. 



Simple 
tests for 
HCl. 



Lactic 
acid. 



When 

abnormal. 



Other fer- 
mentation 
acids. 



* Or, a few drops of resorcin solution (resorcin 5., cane sugar 3., alcohol 
100.), or, phloroglucin solution (phloroglucin 2., vanillin 1., alcohol 100.) 
may be mixed with an equal amount of filtrate in a porcelain capsule or on 
any white surface and evaporated to dryness, a beautiful marginal rose color 
indicating free HCl. 

fThe reaction is intensified by shaking up the tilt rate with ten times its 
volume of ether, evaporating, adding a few drops of water and applying 
test. 



240 



MEDICAL DIAGNOSIS. 



Relative 
impor- 
tance. 



Simple 
tests. 



Relation 
to HC1. 



odor if a bit of calcium chloride be added to an ethereal residue.* 
These volatile fatty acids redden litmus paper held over the tube during 
boiling and indicate fermentation. Lactic acid is the only fermentation 
acid of marked clinical importance; strongly suggesting carcinoma and 
proving fermentation and the absence of the HC1 which normally 
checks fermentation. 

Pepsin and Pepsinogen. — With normal or increased hydrochloric 
acid no test is necessary and in any event pepsinogen may be disregarded. 

Test. — Prepare three tubes, (i). Water 10 c.c. + pepsin 5 grs. + HCl 
dil. 3 drops. (2). Filtrate 10 ex. (3). Filtrate 10 c.c.+HCl dil. 3 
drops, add to each a disc of egg albumin about 1.5 mm. thick, and 
10 mm. in diameter."]" Tube (1) serves as a standard of comparison. 
Digestion in No. 2 indicates both pepsin and HC1; in Number 3. Number 
2 failing, it shows the presence of pepsin or pepsinogen alone. Diges- 
tion should be complete in about three hours at blood heat but con- 
siderable variation is allowable. J As a rule pepsin activity and 
acidity run parallel, but this rule may be departed from in extreme 
hyperacidity and certain cases of subacidity, so also, if motor sufficiency 
be present, even a total absence of acid and ferments may cause few 
symptoms. 

Rennin (lab ferment). — Test. Add to 10 c.c. of milk 3-5 drops of 
gastric contents, keeping mixture at blood heat. The appearance of 
coagulation within 15 minutes indicates rennin. It may be entirely 
absent in carcinoma, achylia gastrica and atrophic gastritis, but is 
the most resistant of the ferments. 

Lipase. — The elaborate test reaction for lipase is of interest only 
to laboratory workers as its only clinical importance lies in the 
diminution or entire absence of this ferment in achylia gastrica or 
atrophic gastritis and this may be assumed if both HC1 and the ferments 
are absent. In any event it is but slightly active. 

Albumin. — This should be absent one hour after a test breakfast. 

Starch. — The digestive transformation of starch begins in the mouth 
where ptyalin rapidly converts it into amidulin. This becomes erythro- 



Most 
resistant. 



Slight 
value. 



Transfor- 
mations, 



* A more exact test for acetic acid demands treatment with ether, evap- 
oration, neutralization of the ethereal residue with dilute sodium hydrate 
and the addition of a drop or two of dilute ferric perchloride, but the results 
are not worth the labor. 

f These should be constantly on hand and are readily prepared, from the 
lightly boiled egg, preserved in glycerine and washed before using. 

±The methods ot Thomas and Weber depending upon the digesting of a 
solution of casein in 0.2% of hydrochloric acid and the still more compli- 
cated one of Mett is too cumbersome for the general practitioner. 



DISEASES OF THE STOMACH. 



2 4 I 



Tests. 



dextrine which strikes a violet or mahogany brown color with Lugol's 
solution. This in turn becomes achroodextrine (unaffected by iodine) 
and maltose (readily detected by Fehling's solution). It is evident that 
if the gastric secretion be normal the hydrochloric acid will prevent 
more than a partial conversion of the starch, despite the rapid action 
of the ptyalin, the extent of which depends upon the thoroughness of 
mastication and the character of the food as swallowed in relation to 
the penetration of the acid encountered. It is checked when the proteid 
affinities are satisfied and free acid appears. 

Clinical Inference. — A marked starch reaction suggests hyperacidity, 
a marked achroodextrine reaction, diminished hydrochloric acid and a 
marked Fehling's reaction decided subacidily or absent HC1. 

Testing the Motor Powerof the Stomach.* — i5grs.of salolshould 
show excretion by the kidney in from 1 to i\ hours and be entirely Saloltest. 
excreted in 27 hours. It appears as salicyluric acid which strikes 
a violet color with ferric chloride; most conveniently applied by plac- 
ing a single drop of the latter upon the wetted test paper. The 
salol is not affected by the gastric juice. Second test. An extremely Rough test, 
simple test consists in allowing a patient to eat cranberries, blackberries 
or other stony fruits at night, removing the contents in the morning 
when the residue show the seeds even if no actual stenosis is present. 
Better probably than either method is the removal of the stomach contents 
in the morning, a full test dinner or ordinary meal having been taken 
the night before. Under these conditions and also two hours after the 
Ewald test meal a stomach should be either entirely or approximately 
empty. In actual stenosis, benign or malignant, solid food remnant 
representing the residue of several previous meals may be present. 
The absorptive power of the stomach may be tested by the administra- 
tion of 10 grains of potassium iodide, in capsules, which should produce 
in the sputum the characteristic iodine reaction with starch paper 
within 10 or 15 minutes. 

QUANTITATIVE TESTS for Free, Total, and Combined 
Hydrochloric Acid. — Take three portions (10 c.c. each) of the 
unfillered gastric contents; add to one 3 or 4 drops of phenolphtha- 
lein solution (1% alcoholic solution). This substance being the indi- 
cator for organic acids, acid salts and both free and combined II CI, upon 
titration with an alkaline solution 0} known composition, will measure 
the total acidity. To the second portion add 3 or 4 drops of alizarine 

*The more elaborate and exact tests of Mathieu, Sahli, Goldschmidt el al. 
have not been included. 
16 



Best 

method. 



Stasis. 



Iodide test 



Total 
acidit: 



242 



MEDICAL DIAGNOSIS. 



DESCRIPTION OF PLATE I. 



A. 
B. 
C. 
D. 
G. 
E. 
H. 



Lactic Acid reaction. 

Test fluid before adding stomach contents in lactic acid test. 

Di-amido-azo-benzol reaction for jree HCl. (qualitative test). 

True terminal reaction for total acidity (Phenolphthalein). 

Antecedent color change in same test, not the terminal reaction. 

Color of stomach contents after adding test solution for jree HCl. 

Terminal color reaction some test. (Color also nearly represents that 
assumed by stomach contents after adding test fluid (alizarin sol) for 
combined HCl). 

Terminal color reaction combined HCl. 

Antecedent color, not true end reaction same test. Test really repre- 
sents all acids in stomach contents except combined HCl (see text), 
the result obtained being subtracted from the previously determined 
total acidity. 



PLATE J. 



A 







Important Coloi Reactions in Connection with the Examination of the 
Gastric Contents. (Drawn from Actual Specimens.) 



DISEASES OF THE STOMACH. 



243 



solution (1% aqueous sol. alizarin monosulphonate of sodium). This 
being the indicator for free acids and acid salts, measures the degree of 
acidity except for the combined HCl (physiologically active acid loosely 
combined with the proteids); hence by subtracting the reading thus 
obtained from the total acidity (which does include the combined acids) 
one gets the amount of the combined acids. To the third portion add 
three or four drops of dimethyl-amido-azo-benzol (0.5% alcoholic sol.); 
this being the indicator for free hydrochloric acid. 

Sol. 1 is cloudy, white or grayish. Sol. 2 a bright yellow. Sol. 
3 a cherry red if free acid be present. The three solutions are now 
each to be titrated with decinormal sodium hydrate solution,* one 
c.c. of which will neutralize 0.00365 gms. of HCl.f When neutrali- 
zation is reached and just passed the true end color reactions appear. 

End Reactions. — These are: — In solution 1 (for total acidity) a 
distinct and persistent red which does not deepen upon the addition of 
more NaOH. In solution 2 (for free acids and acid salts) a pure 
violet color; in solution 3 (for free HCl) a fixed yellow. One must 
carefully note at the commencement of each titration the exact reading 
indicating the height of the solution in the burette and again take it 
on the first appearance of the end reaction. The results may be expressed 
in exact terms by multiplying the amount of acid known to be neutralized 
by 1 c.c. of the NaOH sol. (.00365 gm.) by the amount of that solution 
used and this again by the number of c.c. of filtrate tested. Example. 
Assuming that 6 c.c. are required to neutralize the 10 c.c. of stomach 
contents, and knowing that each NaOH unit neutralizes 0.00365 of 
acid, the formula becomes: — 6 x o.oo365=.o2i9o gms. (for 10 c.c.) 
x io=.2iq%. This is commonly and more conveniently expressed 
by figures based upon the assumption that as 10 c.c. of stomach contents 
required 6 of NaOH for neutralization 100 would require 60, or if 8 were 
used 80, and so on. Using the latter form of notation we find that 
normal free HCl varies from 20 to 40, i.e., .073 to .146%. Total acidity 
from 40 to 60, i.e., .146 to .22% and combined acidity about 25, i.e., 
.09%, one hour after the test breakfast of Ewald or Boas. After the 
Riegel meal (3 hours) the total acidity is about no, free acid 44. 

* A decinormal solutions, \, of the molecular weight of the substance, in 
gms., to 1000 c.c. of distilled water, hence in the case of NaOH the molec- 
ular weight being 40 the solution contains 40 parts to 1000 of distilled 
water. (A normal solution=the molecular weight of the substance in too 
parts of distilled water.) 

fThe fact that the three right hand figures correspond to the number of 
days in the ordinary year is an allowable crutch for a limping memory. 



Combined 
HCl. 



Free HCl. 



Color of 
mixtures. 



Red (total 

acidity I. 

Violet 

(comb. 

HCl). 

Yellow 

(free HCl). 



Actual and 
percentage 

figures. 



Usual 

notation. 



Normals. 



244 



MEDICAL DIAGNOSIS. 



Negligible. 



Rough 
deductions. 



The process is extremely simple and no more complicated methods 
are at all essential for clinical work. It should be remembered that 
if free HCl is present it is the only acid in combination. 

Recapitulation. — Sol. No. i (phenolphthalein) reacts to free acid, 
acid salts, and the loosely combined acids, is grayish white and cloudy 
and gives a red terminal reaction. Sol. No. 2 (alizarin) measures 
the same acid contents as No. 1 less the loosely combined acid, thus neces- 
sitating for an estimate of the combined acid the subtraction of the result 
obtained, from the figures representing the total acidity. The original 
color of No. 2 is yellow, the end reaction violet. Sol. No 3 (dimethyl- 
amido-azo-benzol) reacts only to free acid, is originally cherry red, 
and its end reaction is a brilliant yellow. Finally, the normal total 
acidity is 40-60 (.146 to .22%); the combined acidity 25 (.oq%); the 
normal free HCl 20-40 (0.73 to .146%) after a test breakfast. 

Sources of Error. — Topfer's method as here given is by far the 
most accurate and convenient for clinical work and while slightly inac- 
curate when free hydrochloric acid is absent especially in the presence 
of an excessive amount of the organic acids, these errors are not suffi- 
cient to disqualify the test for the general practitioner.* 

Effects of Diet. — Variations in acidity, particularly in free acid, will 
of course depend somewhat upon diet and an excessive amount of saliva 
may neutralize the gastric contents; in such cases the addition of a few 
drops of dilute HCl and 2 or 3 drops of ferric chloride solution to the 
stomach contents causes a red color reaction. As the acid affinities of 
starchy foods are readily satisfied and the demands of proteid substance 
much greater, the highest acid values are found in meat eaters and the lowest 
in vegetarians. The more liberal the diet and the better the nourish- 
ment the more the acid. It is evident also ihat the real value of our 
figures is represented by the" combined" and "free" acid percentages. 

The Diagnostic Bearing of the Foregoing Methods. — For hasty 
work the mere determination of free HCl is most readily achieved by 
the use of congo-red paper easily procured of any chemist though it tells 
us nothing save the bare fact that HCl is present. This being the case 
however the presence of normal ferments is usually a fair presumption. 
Wood warns the physician against placing too much dependence upon 
the first test meal, rightly stating that, owing to the emotional dis- 
turbance, the results may be misleading. The same rule may be 

* The methods of Sahli, Reissner, Martius and Luttke may be found in 
works devoted to clinical diagnosis, but are too complicated for the use of 
the practising physician. 



HR 



DISEASES OF THE STOMACH. 



245 



applied to several successive tests, if, as seldom happens, the nervous 
disturbance continues to be excessive. Ordinarily we have to consider 
four conditions. 

(1). NORMAL ACIDITY (euchlorhydria). This excludes achylia 
gastrica, chronic gastritis and usually carcinoma of the stomach. It 
does not exclude gastric atony and dilatation, nervous dyspepsia or the 
rare cases in which carcinoma develops upon an old ulcer base.* 

(2). HYPERCHLORHYDRIA (0.2% +).— We distinguish be- 
tween the secretion of excessively acid gastric juice during digestion 
(hyperchlorhydria proper) and the same condition appearing in the 
fasting stomach and representing more or less continuous hypersecretion 
{gastrosuccorrhcea (a) continuous— TeichmanrCs disease, or (b) periodic or 
intermittent — RossbacK's disease). As regards hyperchlorhydria proper, 
its chief clinical importance depends upon its frequent association with 
ulcer of the stomach and the possibility that it is a factor in the pro- 
duction of that lesion. Simple hypersecretion moreover is common in 
neurotics without ulcer symptoms, in the gastric crises of tabes dorsalis, 
biliary engorgement, and, as a temporary condition due to exhaustion, 
emotional disturbance, constipation, dietetic errors, overuse of alcohol 
and tobacco or even to special articles of food. 

Symptoms. — Its symptoms are no doubt chiefly due to an asso- 
ciated hyperesthesia of the mucosa. The most characteristic feature 
is the combination of slight or decided digestive disturbance (epigas- 
tric oppression, pyrosis, regurgitation, nausea, perhaps vomiting and 
occasionally diffuse pain and headache) with a clean tongue. The 
attacks appear from one to three hours after a meal, are relieved if 
vomiting occurs, or often (temporarily) by taking nitrogenous food and 
are in all cases ameliorated by the administration of an alkali. Slight 
diffuse tenderness may be present and constipation is the rule. The 
stomach contents are usually clear, acrid to the taste, of low specific 
gravity and will of course show high acid valuesf and unconverted 
starches. The urine at the height of an attack is usually neutral and 
deposits phosphates. In acute attacks the pain may be severe and 
strongly suggests ulcer save that it is more diffuse, is relieved rather than 

* A case showing a gradual transformation from the symptoms and find- 
ings of ulcer to those of terminal pyloric carcinoma has recently hern under 
the author's observation. The distinctions while in general correct are b\ 
no means invariable (see gastric ulcer for further discussion). 

fAfter a test break) ast the free acid which is the determining factor will 
exceed 50, the total acidity 7c. The stomach is frequently entirely empty 

one hour after the meal because of coincident increased motor activity. 



Variable 
findings. 



Ck 



Various 
associa- 
tions. 



Sugges 
tive. 



Dietetic 

and drug 
tests. 



Macro- 
scopic and 
chemical. 



A 



246 



MEDICAL DIAGNOSIS 



increased by taking nitrogenous food and the condition itself in most 
cases readily corrected by attention to diet and proper rest and recrea- 
tion. Anaemia and other evidences of marked malnutrition are fre- 
quently absent but may result from limitation of ingesta. The appetite 
is frequently unimpaired, more often variable. 

CHRONIC HYPERSECRETION.— This includes two chief forms 
of hypersecretion usually marked by decided hyperacidity. In Teich- 
mann's disease the increase of stomach contents in the fasting 
stomach is continuous. Though closely following the etiology of sim- 
ple hyperacidity it is often associated with ulcer and may occur in 
pyloric stenosis, simple dilatation or chronic gastritis with impaired 
motility. It is a mere syndrome. 

Rossbach's disease, (nervous gastroxynsis) also frequently asso- 
ciated with gastric ulcer, may be merely a chronic form of what was 
primarily simple hypersecretion. The symptoms are those of the ordi- 
nary "bilious attack" with nausea, bilious vomiting, epigastric distress 
and diffuse pain and tenderness. It is recurrent, lasting from one to 
several days at a time and hardly deserves a place amongst actual dis- 
eases. Between the simple hyperchlorhydria and chronic hypersecre- 
tion stands the so-called "alimentary hypersecretion" which occurs 
only at the normal digestion periods, the contents showing often an 
excess of 50-200 c.c. over the amount of ingesta. 

Comment. — Admitting that for the present the foregoing classifica- 
tion of hyperchlorhydria and hypersecretion must be preserved, the 
utmost caution is necessary in accepting it in the individual case, 
because of the frequency of unrecognized gastric ulcer and the tenu- 
ousness of the differential lines drawn. It is true however that in 
ulcer the pain and tenderness are more distinctly localized, yet often 
both these symptoms and hemorrhage are entirely absent, the ulcer going 
quietly on to spontaneous recovery or perforation. The crises of 
locomotor ataxia moreover may be associated with either hyper or hypo- 
chlorhydria. 

(3) HYPOCHLORHYDRIA (0.1— ). Low HC1 values point to 
subacute or chronic gastritis but are frequently met with in early carci- 
noma, certain late forms of gastric ulcer, duodenal ulcer, dilatation with 
or without stenosis, the early stage of achylia gastrica and also in 
chronic disease of the gall-bladder, pancreas and vermiform appendix. 
Its value as a positive symptom is therefore slight. 

(4) ANACHLORHYDRIA— As a symptom this is of positive and 
decided value, though met with in certain cases of advanced chronic 



Amemia. 
Appetite. 



Continu- 
ous. 



A mere 
syndrome. 



Recurrent. 



Simulate 

surgical 

conditions. 



Aliment- 
ary. 



Caution. 



Indetermi- 
nate. 



GASTRIC NEUROSES. 



247 



gastritis as well as nearly all gastric carcinomas, pernicious anaemia, 
and, in achylia gastrica and true atrophic gastritis, in which there is also 
an entire absence of the normal ferments. Unfortunately, according to 
the author's experience, many cases of dyspepsia apparently purely 
nervous, and especially those accompanied by marked malnutrition 
due to the common cause (viz.: — chronic starvation induced by fool- 
ishly restricted and monotonous diet), show this condition, the acid 
reappearing after a short period of treatment. The sign is therefore 
chiefly valuable in connection with the associated symptoms (see acute 
and chronic gastritis, cancer of the stomach and achylia gastrica). 

Heterochylia. — This is merely a convenient term covering the cases 
of decided intermittent variations in secretion. It may occur in health 
or in any form of gastric disturbance, functional or organic. 

GASTRIC NEUROSES AND CERTAIN PROMINENT GAS- 
TROINTESTINAL SYMPTOMS.— Aside from the hypersecretions 
previously discussed we may encounter neuroses relating to pain, ten- 
derness, peristaltic action, eructations, vomiting, motor spasm or relaxa- 
tion, appetite and various paresthesias. 

Appetite. — Anorexia: — Loss of appetite though related to many 
conditions may be described under this head. It is present in all 
fevers, in many chronic exhausting diseases and under the stress of 
violent emotion (grief, worry, anxiety), may be purely hysterical or 
neurasthenic and may take the form of mere loss of the hunger sense, 
actual repulsion, a sense of repletion, actual perversion, or, nausea 
upon taking a slight amount of food. Chlorosis, chronic alcoholism, 
hysteria, nervous and emotional overstrain, influenza and septic proc- 
esses including advanced tuberculosis are some of the best known 
examples, but again the author would emphasize the frequency of chronic 
anorexia as the result of dietetic fads and fancies and narrowed mon- 
otonous dietaries.* 

Bulimia. — An insatiable and inordinate craving for food is one of 
the marked symptoms in certain cases of true diabetes and occurs 
normally in convalescence from fevers such as typhoid and the exanthe- 
mata. It is met with as a nervous or hysterical manifestation as well 
as in cerebral disease, epilepsy, exophthalmic goitre, etc. In the hysteric 
and neurasthenic cases it may be associated with an absence of the sense 
of satiety (achoria) or there may be a craving for unusual, seemingly 



Fool diet: 



* Again and again the most obstinate cases of dyspepsia with complete 

anorexia and excessive emaciation are promptly relieved under the rest cure 
and the gradual introduction of a varied and generous dietary. 






Children' 
likings. 



Nervous 
mechan- 
ism. 



Long list 
of causes. 



248 



MEDICAL DIAGNOSIS. 



or actually injurious, or possibly, disgusting articles, as is observed in 
hysteria, pregnancy, chlorosis and to a less degree in childhood, where 
it no doubt oftentimes represents in normal children a genuine struc- 
tural need in so far as it relates to special types of ordinary food, the 
craving for sweets and fruits or the preference shown for an exclusive 
starchy or proteid diet being too often combated by parents. 

NAUSEA AND VOMITING.— May be either central or per- 
ipheral in origin, the centre being closely related to the respira- 
tory centre in the medulla. Motor impulses to the diaphragm follow 
the phrenic nerve; to the abdominal muscles, the intercostals; while its 
sensor) r message follows the vagus. In gastric disease the act is dis- 
tinctly reflex, in toxaemic conditions chiefly central. Purely psychic 
influences are capable of producing it as is seen in hysterical vomiting 
and that associated with profound emotion or mental shock. Its 
relation to special sensation is shown by the response to foul odors, 
disgusting tastes and shocking spectacles. 

Toxaemic Vomiting. — The toxines may be bacterial as in the exan- 
themata, pneumonias, malaria, or severe infections in general, or non- 
bacterial, as in uraemia, diabetes, Addison's disease, profound anaemia 
or certain autointoxications. Furthermore one must consider the 
action of such drugs as apomorphia, ether and chloroform and the effect 
of deleterious gases and the overuse of alcohol. 

Reflex and Central Vomiting. — As a precursor or accompaniment 
of apoplexy so also as a result of brain tumor, meningitis, thrombosis 
and embolism, vomiting may be a marked and somewhat suggestive 
feature. In anaemia both autointoxication and cerebral disturbance 
must be considered. It occurs in shock, collapse and occasionally 
in severe concealed hemorrhage, Meniere's disease, migraine and in 
the muscular insufficiencies and refractive errors seen by the oculist. 
Vomiting attending disturbances of equilibrium as typified by sea 
sickness is well known and in diseases of the abdominal organs the stomach 
is of course the most frequent cause of reflex vomiting whether there 
be actual inflammation, irritation, flatulence or mere disturbances of 
secretion. Under similar conditions it may attend ailments of related 
or neighboring organs such as the large and small intestine, the appendix, 
the rectum, liver, gall-bladder, pancreas, kidney and peritoneum. 
As regards the respiratory tract vomiting is readily induced by direct 
titillation of, or foul secretion adherent to, the naso -pharyngeal mucous 
membrane and may be associated with paroxysmal cough as in pertussis 
i or pressure from mediastinal tumors. Circulatory causes aside from 



NAUSEA AND VOMITING. 



249 



Bile. 



anaemia and cerebral congestion or hemorrhage may be due to direct 
pressure, as in pericardial effusion, or a secondary congestion of the 
abdominal viscera in valvular or myocardial disease. Aside from 
the kidney the urinary tract is an infrequent source of vomiting but the 
genital tract furnishes many examples as in the vomiting of pregnancy, 
uterine displacement and ovarian or testicular disease. 

Points to be Especially Noted. — These are (a) frequency, (b) the 
time of day or night, (c) pain and its persistence or intractability, (d) 
associated nausea, (e) its relation to meals both as to the character of 
the food and the time elapsing after ingestion, (f) the character of the 
vomitus, viz.: — amount, color, taste, the presence of remnants of remote 
meals, and blood bright red, dark or of the " coffee grounds" variety. 

The Vomitus. — The general appearance of vomited material is too 
well known to need description and it is the significant variations that 
demand our attention. The amount, scant or excessive, suggests | Amount 
hyperacidity and excessive motility on the one hand, hypersecretion, 
dilatation or atony upon the other. Vomitus from a fasting stomach 
if clear and of a sharply acid taste and odor suggests hypersecretion, 
if the mucous content be large and the tongue coated gastric catarrh 
is suggested. Distinctly bilious vomiting is a common indication of 
acute indigestion but if persistent may also point to pyloric incom- 
petence or duodenal stenosis, simple, or associated with ulcerative 
or malignant infiltration, to peritonitis, or, to intestinal obstruction. 
In the two latter conditions the vomitus soon presents an unmistakable 
fecal odor. Mucus may be intimately mixed with food residue and 
vomited at the outset as in gastric catarrh; is flocculent in hyperacidity 
and tenacious and stringy in anacidity. In hyperacidity it is soon 
dissolved and so usually points to sub or anacidity if present at the 
height of digestion. Pus may be visible in rare instances of gastric 
abscess or through fistulous communication with abscesses of other 
organs. In cases of poisoning the characteristic odor of the toxic 
substance may be evident and in cases of stasis and marked fermentation. 
butyric, acetic or valerianic acids may be detected. In advanced 
ulcerative carcinoma or in the presence of foul purulent material from 
whatever source the odor may be peculiarly putrefactive and in uraemia 
ammoniacal. Various parasites may be evident to the naked eye, 
such as round worms, thread worms and segments of tape worm. 
The color is, aside from food admixture and discoloration, yellow in 
anacidity, green from bile contamination or the development oi certain 
yeasts, but is ordinarily dirty gray or greenish brown and, rarely, rose 



Parasite: 



Peculiar 

tints. 



25° 



MEDICAL DIAGNOSIS. 



" Coffee 

grounds. 9 

Clots. 



How 

simulated. 



Amount. 



color from bile decomposition with high acidity or in the crisis of tabes 
dorsalis (Lorenz) with hypersecretion. Bile may be present in any 
vomitus if the efforts are prolonged. Occurring at the outset or in 
repeated slight attacks it strongly suggests pyloric or duodenal infiltra- 
tion, in the latter case pancreatic secretion may be demonstrated by the 
digestive activity of the vomitus in alkaline media. 

Haematemesis. — If the blood be recently effused it is bright red and 
fluid, if partially digested it resembles coffee grounds, if in an inter- 
mediate stage and in sufficient quantity it may be clotted. The appear- 
ance of blood is simulated by jellies and jams, cocoa, coffee, beef juice, 
such drugs as iron and bismuth, the dark red wines, grape juice and 
fruits such as currants, cranberries and cherries. The amount of blood 
may be large or small and the small amounts may be derived from any 
source, indeed a mere streaking of mucus may accompany excessive 
and persistent vomiting and indicate no serious lesion. On the 
other hand, hemorrhages of all degrees occur in ulcer and carcinoma, 
splenomegaly, certain cachetic conditions of the hemorrhagic type such 
as advanced leukaemia, haemophilia, scurvy and purpura, virulent infec- 
tions chiefly associated with tropical fevers, such as yellow fever and 
pernicious malaria and, the action of irritant and corrosive poisons. 
Blows and wounds, the varices of portal obstruction, chronic heart 
disease and vicarious menstruation must be considered. 

Sources of Error. — In nose bleed, haemoptysis, ruptured tonsillar 
abscess and similar conditions the blood may be swallowed and its 
source may be recognized only through the presence of the causative 
factors named. In haemoptysis, the blood is bright red, frothy and 
of alkaline reaction; there are usually physical signs, cough and often 
distinctly localizing subjective sensations.* 

Chemical and Microscopic Tests for Blood. — The following test 
will apply equally to blood in the stools and in the stomach contents 
and it must be remembered that an examination of the stools is of the 
utmost importance in all cases of supposed carcinoma or gastric ulcer, 
vomiting being frequently absent and slight hemorrhages unrecognized. 

Weber's Test demands that a portion of the suspected material 
placed in the test-tube be treated with several drops of strong acetic 
acid and shaken up thoroughly with one-third its volume of ether, 
the supernatant ether is pipetted off and if necessary cleared by adding 



Hsmoo- 
tysis. 



Stools or 
stomach 
contents. 



* Though in haemoptysis the blood is raised by coughing, vomiting is a 
frequent accompaniment and may predominate, the cough being slight. 
Hence too much stress should not be laid upon this as a differential factor. 



DISEASES OF THE STOMACH. 



251 



a few drops of alcohol and the solution should then show an absorption 
band* of acid hematin by the direct vision spectroscope. Guaia- 
cum Test. — To the ethereal extract may be added 10 drops of freshly 
prepared tincture of guaiac and double the amount of old turpentine, 
blood being indicated by the bluish or purple color, which can be 
extracted and better defined if shaken up with chloroform. The alco- 
holic extract of Barbadoe's aloin may represent the tincture of guaiac 
in this test and is less liable to disturbance from free HC1. 

Teichmann's Test requires the careful evaporation of the suspected 
material on the slide after which a crystal of sodium iodide or sodium 
chloride is added, followed by a drop of glacial acetic acid. Too rapid 
evaporation is prevented by the use of a cover-glass and it is then gently 
heated to the exact boiling point, fresh acid being added as evaporation 
goes on. When a brown color appears, indicating the formation of 
hemin, complete evaporation is allowed and a drop of water run under 
the cover-slip. The microscope will then show the characteristic black 
or brown rhomboidal crystals of hemin. Iron causes no disturbance of 
the chemical tests for blood. 

Microscopic Findings. — The food detritus depends upon the charac- 
ter of the meal previously taken and the time elapsing since its ingestion, 
but, in general, consists of muscle fibres and starch granules more or 
less changed by cooking and digestion, the former being recognized 
by their markings, the latter by their peculiar form and structure 
or their blue reaction with LugoPs solution. Skins of fruit, seeds of 
berries or even more digestible substances remaining from remote 
meals point to impaired motility or actual stenosis, saliva is indicated 
by pavement epithelium and the so-called salivary corpuscles and the 
various vegetable cells are usually so peculiar and bizarre as to at once 
suggest their nature. Fat may appear in the form of crystals or of 
the highly refractile droplets soluble in ether, staining orange red with 
Sudan III and black with osmic acid (1%). The presence of a few 
red blood corpuscles after vomiting or the passage of a stomach tube 
is not necessarily pathologic. Mucus may be present in all degrees 
according to the nature of the lesion but is rarely absent entirely even 
if HC1 be present and may take the form of snail like masses. Such 
mucus is likely to be from the buccal cavity or esophagus. 



Best 

method. 



Valuable 
test. 



Starch and 

muscle 

fibres. 



Indigesti- 
ble residue. 



Saliva. 



Fat. 



Micro- 
scopic 
blood. 



Mucus. 



*The absorption spectrum consists of one strongly defined band in the 
red and three less defined or often entirely absent. (One in the yellow, one 
between the yellow and the green and another between the green and the 
blue.) 



252 



MEDICAL DIAGNOSIS. 



Boas- 

Oppler 
vs. 
Leptothrix. 



Yeasts. 



Often mis- 
leading. 



Vegetable Parasites. — The Boas-Oppler bacillus, the sarcina ven- 
triculi, the leptothrix buccalis and the tubercle bacillus are the most 
important. In carcinoma the Boas-Oppler bacillus is present in the 
form of large long rods frequently arranged in chains and staining 
brown with Gram's solution, whereas the leptothrix which resembles 
it stains blue. It not only indicates large amounts of lactic acid but 
is present in 80% or more of the cases of cancer of the stomach and nearly 
always absent in simple dilatation or benign stenosis* The sarcince 
on the contrary are present in large numbers in these benign cases though 
rarely in acute or chronic gastritis, simple atony, ulcer and cancer of the 
stomach. Both the large and small variety appear usually as if arranged 
in bales. Yeast fungi are present in large numbers in marked degrees 
of atony or ectasia and, in high acidity, unchanged starch granules will be 
plentiful, and in subacidity the. muscle fibres will be correspondingly 
numerous in their definite and unchanged form. The Boas-Oppler 
bacilli usually abound in the larger clots sometimes met with in cancer. 

Cancer Cells. — Rarely one finds detached particles of new growths 
but more often such fragments are absent or unrecognizable. 

"Heart Burn," (" Pyrosis " or " Water Brash ") covers a regur- 
gitation of stomach contents common in many forms of gastric disturb- 
ance, and merycismus (rumination), usually observed in neurasthenia, 
hysteria, idiocy or epilepsy, covers voluntary regurgitation and remasti- 
cation of the food. 

Peristaltic Unrest (supermotility, hyperkinesis). — This trouble- 
some excessive motility, is accompanied by noisy gurgling and rapid 
emptying of the stomach, but may occur in the empty organ. It is 
a common transient phenomenon but may be persistent in hysteria 
and neurasthenia. 

Eructation (pneumatosis, belching, flatulence). — This common 
phenomenon needs no explanation. Ordinarily negligible, it is a per- 
sistent, troublesome and characteristic symptom in certain nervous 
dyspepsias associated with marked neurasthenia or hysteria. The 
term "pneumatosis" is properly applied to the condition of extreme 
distension of the stomach by air swallowed by certain dyspeptics or by 
malingerers. 

Gastric Spasm. — Spasm may occur either at the cardia or pylorus 
and both may be purely nervous phenomena, the former almost 
invariably so, the latter being most frequently associated with hyper- 

* They are reported by Heichelheim as present in small numbers even in 
the carcinomatous stomachs showing high acid values. 



NERVOUS DYSPEPSIA. 



253 



may be a subjective localized sensation of 
be painful and the latter may produce 



A rare 
condition. 



acidity; in either there 

obstruction, both may 

visible or even reversed peristalsis and, if long continued, lead to actual 

dilatation. If the two conditions are simultaneous (invariably neurotic) 

the marked overdistension may be evident. 

Gastric Hypersesthesia. — Marked gastric intolerance with a sense of 
weight, fulness or burning and without an organic basis may be encount- 
ered in hysteria, neurasthenia, exhausting and debilitating disease, 
mental and physical overstrain, profound anaemia, shock, and forced 
or voluntary fasting for long periods. It may be associated with marked 
diffuse tenderness corresponding to the stomach outline and is probably 
the chief cause of symptoms in hyperchlorhydria. 

Gastralgia has been previously referred to as a misused term represent- 
ing in most instances appendicitis, gall stones, gastric ulcer or cancer, 
the gastric crises of locomotor ataxia, splanchnic arterio-sclerosis 
or angina pectoris. A true neuralgia of the stomach is exceedingly 
rare. 

NERVOUS DYSPEPSIA (combined gastric neuroses).— These 
terms, of which the second is the more descriptive, cover certain forms A neurosis 
of gastric disturbance prolific in subjective, barren in objective symptoms 
and commonly associated with nervous overstrain, shock, grief, 
worry, frank neurasthenia or hysteria, or, due to reflex causes such as 
chronic appendicitis, pelvic disease, and movable kidney. It is essen- 
tially a mere syndrome. The tongue is usually clean or lightly furred Tongue 
and may show some swelling and lateral indentation. When the stomach 
is empty the patient may complain of faintness and a "gone" sensation 
in the epigastrium, headache, or a sense of cerebral pressure or dulness, 
marked subjective weakness and palpitation after taking food. There 
is troublesome distension, eructation and oftentimes peristaltic unrest 
associated with pyrosis and irritating borborygmi. Dizziness, epigas- 
tric pulsation and a globus hystericus may be encountered. The gastric 
contents are usually normal but may show hyper-, hypo- or a temporary 
anacidity. Heterochylia is common, and malnutrition may or may not 
be marked, Persistence of symptoms is due to an unduly restricted or 
monotonous diet, lack of rest (mental and physical) proper recreation and 
diversion and a pernicious and persistent form of introspection. Many 
of these cases require absolute rest, isolation, a gradually increased 
and ultimately generous diet, absolute control by a specially trained 
nurse, the oversight 0} a competent physician and a modicum of common 
sense and will power as a leaven. 



Suggestive 
symptoms. 



" Globus 

hysteri- 
cus." 

1 [etero- 
cylia. 

Had diet 



Introspec- 
tion. 



254 



MEDICAL DIAGNOSIS. 



May be 

fatal. 



ANOREXIA NERVOSA.— This curious condition characterized by 
absolute loss of appetite and frequently by abhorrence and rejection of all 
foods, may follow prolonged fasting (starvation "cures"), shock, grief and 
the like, or, as is usually the case, be associated with hysteria or profound neu 
r asthenia. In hysterical cases especially, the patient may be profoundly an- 
aemic, will promptly vomit all food administered, complain of vague and 
often shifting abdominal pain and tenderness, and frequently pretend to 
vomit blood, or, if posted, imitate the painful crises of ulcer. Emacia- 
tion may be extreme and a fatal issue is possible if proper treatment 
is not available. Absolute rest, isolation, and firm control by a competent 
nurse and physician will usually clear up the diagnosis and cure the 
patient. One of the most characteristic features is the almost instant 
vomiting of the food though usually water will be retained and frequently 
the act is one of mere regurgitation. 

ACHYLIA GASTRIC A SIMPLEX (apepsia).— This interesting 
ailment or syndrome is of unknown causation and affects adults almost 
or quite exclusively. So long as intestinal digestion remains unaffected 
few or no symptoms are produced yet an examination of the stomach 
reveals complete loss of HC1 and digestive ferments and a diminished 
secretion of fluid. There is no pain, the fasting stomach is empty and 
one hour after a test breakfast the residual content is small but wholly 
unchanged and lacking mucus or any sign of fermentation. Micro- 
scopically one finds unchanged proteid and advanced starch digestion 
(ptyalin in the absence of HC1. Fehling's test will be positive, the 
iodine test for unchanged starches negative. Motility is increased as 
might be expected and the intestinal juices complete the process, In 
advanced cases the intestine may become the scat of irritation and 
catarrhal inflammation and the stools show imperfect digestion of the 
proteids. In such cases indicanuria is marked. In genuine simple 
achylia gastrica the mucous membrane is not atrophied but is readily 
injured and abraded. 

GASTRIC ATROPHY (achylia gastrica with atrophy).— The first 
term is preferable and should be limited to those cases of anachlorhydria 
and apepsia in which atrophy is secondary to no other ailment, such as 
carcinoma local or remote, and especially fits cases presenting the blood 
picture of pernicious anaemia, though this symptom may in certain 
cases be lacking. 

Diagnosis is assisted by the following factors: — dyspeptic symptoms 
and even pain may be marked, indeed anorexia or aversion to meats 
may occur exactly as in carcinoma, but, unlike the latter, thefermen- 



Remarka- 
ble find- 
ings. 



No gastric 
digestion. 

Increased 
motility. 



Misleading 
signs. 



GASTRIC ATONY. 



255 



tation acids are absent and there are no evidences of stenosis or dilata- 
tion. Intestinal symptoms may supervene and the usual anaemia may 
assume any grade. The picture then is usually one suggesting either 
carcinoma or pernicious anaemia but lacking the lactic acid and Boas- 
Oppler bacilli and the evidences of stasis and dilatation so common in 
carcinoma. High grade anozmia superadds its own symptoms. 

Symptomatic Hypochylia and Achylia. — To the foregoing must 
be added the purely secondary diminution or complete absence of HC1 
and the ferments. It may play a part in the cachexia of terminal 
nephritis, diabetes and tuberculosis, is not infrequent in severe chronic 
catarrhal gastritis with atrophy or the anachlorhydric form of gastric 
ulcer and is present in 80% of the carcinomata, local or remote. 

Summary. — Achylia gastrica may be (a) symptomatic or secondary, 
(b) associated with primary gastric atrophy or (c) occur as a definite 
syndrome without marked subjective disturbance being almost symp- 
tomless save for the gastric findings unless intestinal irritation supervenes. 

Diagnosis. — No diagnosis should be made of either the atrophic or 
simple form until all possible primary sources have been excluded. 
The atrophic form is suggested by symptoms of carcinoma, erosion, or 
profound anaemia, but lacking certain of their gastric findings; simple 
achylia by the astonishing lack of severe symptoms with an entire 
absence of proteolytic agents. 

DISORDERED MOTILITY.— Hypermotility has already been 
touched upon and is marked in hyperacidity and present in achylia, 
some cases of diabetes mellitus, tape worm and the ingestion of certain 
drugs such as pilocarpin and strychnine. 

Motor insufficiency may be due to actual atony and the term is less 
properly applied to the stasis produced mechanically by pyloric 
stenosis as in these cases there may be actual hypertrophy of the muscular 
layers and, for a time at least, partial compensation. Dilatation results 
from the stasis of either myasthenia or stenosis. 

GASTRIC ATONY.— An attempt to sharply classify the various 
conditions associated with muscular insufficiency or actual dilatation 
of the stomach leads to much confusion and it is better to consider 
the stomach and its musculature exactly as one would the heart. Either 
organ may be abnormally large yet perfectly competent. In the case 
of the stomach this interesting but symptomless condition is known 
as megalogastria. Weak musculature, resulting in lessened motor activ- 
ity and relaxation 0} the muscular walls constitutes true atony of the 
stomach and as in the case of a chronically weak heart leads to lessened 



A n ae m i a 
perhaps 
extreme. 



A remarka- 
ble fact. 



Three 
types. 



Seek a 

primary 

cause. 



Atony 

vs. 
Stasis. 



Megal 

tria. 



- 



'256 



MEDICAL DIAGNOSIS. 



Ectasia 



Stasis. 




Fig. 116.— Dilated stomach. Combined dis- 
placement and dilation of lesser degree. (After 
Riegel.) 



effective functional activity. Finally, if an actual obstruction exists at 
an exit, the stomach and the heart act alike in that they try to over- 
come, by increased action and hypertrophy of the muscle, the mechan- 
ical obstacle or, if this is not possible, to undergo passive dilatation with 

consequent stasis. The par- 
allel is quite exact and helps 
to clear up this subject which 
is involved in a maze of con- 
tradictory opinions even at 
the present time. Disregard- 
ing megalogastria we have 
first to deal with gastric atony 
or myasthenia and its inevi- 
table accompaniment, de- 
creased motility from "mus- 
cular insufficiency." This 
may exist without marked or 
permanent dilatation in any 
degree, but persistence of muscle weakness combined with prolonged 
retention of the stomach contents of itself tends to produce a secondary 
dilatation (ectasia) varying greatly though less commonly reaching an 
extreme form than is the case in actual mechanical obstruction. Hence 
we find that in atony consider- 
able degrees of dilatation are 
possible without the extreme 
manifestations of gastric stasis 
and fermentation encountered 
in pyloric stenosis. In this 
last condition as in stenosis of 
the aortic orifice of the heart 
unless myasthenia or atony 
pre-exists there is primarily an 
hypertrophy of the muscular 
coats which may for a long 
time prevent extreme dilata- 
tion or marked stasis. Ulti- 
mately, however, either because the stenosis becomes more extreme or 
the muscular weakness predominates over hypertrophy, marked dilata- 
tion occurs with an increased degree of myasthenia and resulting stasis. 
Gastroptosis. — Any case of dilatation if marked may be associated 




Fig. 117.— Dilated and displaced stomach 
(crescentic form). Outline— personal observa- 
tion. (Figure after Riegel). 



DISEASES OF THE STOMACH — ATONY. 



257 



Chronic or 

acute. 



Etiology 
varied. 



with varying degrees of displacement (ectasia with gastroptosis) but Ectari 
marked ptosis may exist without dilatation (gastroptosis proper). 
Having the preceding factors in mind, one may proceed to discuss the 
conditions under three chief heads. 

(1) Atony (myasthenia, "relative", "motor" or facultative insuffi- 
ciency). — This covers the non-obstructive form and may be primary, 
secondary, acute or chronic and associated with merely temporary 
dilatation or abnormal distensibility, or, true ectasia. In rare instances 
acute, oftentimes fatal dilatation occurs, a condition of special impor- 
tance in connection with heart disease, arterio -sclerosis, the acute 
infections and major operations, particularly of the abdominal type. 
Chronic dilatation of an extreme form may be seen in the employes 

of breweries or others who are 
gross eaters and heavy beer 
drinkers. No other disease is 
richer in etiologic factors, 
amongst which are heredity (it 
may be congenital), nervous 
shock, grief, worry, mental or 
physical overstrain, exhausting 
diseases, overeating and drink- 
ing, epilepsy, migraine, brain 
injury, abdominal traumatism, 
overuse of tobacco and alcohol, 
and finally, nervous dyspepsia, 
hepatic cirrhosis, pancreatitis, 
cholelithiasis, chronic constipa- 
tion, chronic appendicitis and certain acute infections (typhoid, diph- 
theria, scarlatina, etc.). 

The Symptoms. — Subjectively, the symptoms are those described 
under nervous dyspepsia save that in many cases of atony the patient is 
symptom free when the stomach is empty. The slightest quantities of 
food give the sensation of repletion and distension and there is obstinate 
constipation. Objectively, one notes abdominal distension and often- 
times visible gastric enlargement with or without gastroptosis yet the 
milder cases may show merely excessive distensibility, as revealed by infla- 
tion, or the low level of dulness resulting from the ingestion of a pint of 
water. The gastric outline is usually markedly extended to the right as 
well as downward and contrary to the findings in stenotic cases, visible 
or palpable peristalsis is lacking or slight. Succession, both superficial 
17 





Fig. 118.— Simple Gastroptosis. 
observation. (Figure after Riegel. 



Personal 



Inefficient 
muscula- 
ture. 



Distensi- 
bilitj or 

ectasia. 



. 



258 



MEDICAL DIAGNOSIS. 



Salol test. 



Ultimate 

slight 

stasis. 



A cause of 

sudden 

death. 



Obstruc- 
tive in type. 



Various 
causes. 



and deep, is apparent even 6 or 7 hours after a meal and is abnormally 
low in position. Salol excretion (see page 241) is delayed and residual 
food will be found 7 hours or more after the Riegel dinner, though usu- 
ally absent if the meal has been retained over night. If the case be 
watched from day to day marked variations in the size of the stomach 
may be noted, and, finally, the stomach contents may show a relatively slight 
degree of stasis as indicated by fermentation , though the stomach find- 
ings vary greatly and are not in themselves distinctive. 

Acute Atony. — Terrifying epigastric oppression, violent dry retch- 
ing, or, more rarely, slightly ^ .-^^^w_ -" 
productive vomiting, actual ^ 
pain, and belching followed 
by persistent gaseous disten- \ 
1 sion, cold extremities and a 
weak and rapid pulse, mark 
an ailment less often recog- 
nized than it should be as a 
cause of severe illness and 
relatively sudden death. 

Post-stenotic Motor 
Insufficiency. — Here ac- 
tual obstruction not mere 
loss of muscle tone is the 
chief factor, indeed, actual 
muscular hypertrophy may 
be present in a dilated 
stomach as in the case of the heart with valvular incompetence. 
Etiology. — Whatever causes produce obstruction of the pylorus 
or duodenum may cause gastric dilatation and insufficiency. It 
may follow operations upon the stomach, duodenum or gall-bladder, 
pyloric tumors or hypertrophy, congenital or acquired,* pyloric spasm 
(see p. 253) and obstructive scars or deformities. Even tight corsets or 
plaster jackets may produce chronic obstruction and dilatation. 

Symptoms. — The symptoms of simple nervous dyspepsia or myas- 
thenia predominate but pain may be present and be severe, paroxysmal 
and attended by violent visible peristalsis or palpable contractions, or, 
on the other hand, it may be absent or replaced by or associated with 



Fig. 119.— Dilated stomach, combined displace- 
ment and dilation. Slightly modified to conform 
to personal observations. (After Riegel.) 



* Congenital stenosis is far commoner than has been supposed. Three cases 
(Drs. J. U. Goodrich, P. A. Hoff and W. Ramsey) having been brought to the 
author's attention within 90 days; all confirmed by autopsy. 



DISEASES OF THE STOMACH — ATONY. 



259 



Usually 

frank. 



Stasis 
signs. 



extreme epigastric oppression or distension with or without tender- 
ness. 

Objective symptoms are readily elicited. The stomach is often visi- 
bly distended or if inflated appears in characteristic but enlarged outline 
with or without displacement (gastroptosis) and is readily palpated. | 
Increased resistance may be noted as well as rhythmically intermittent 
rigidity. Peristalsis may or may not be visible but is most marked 
during painful crises, if such are present, or shortly after a meal. As 
in the heart, long persistence of stenosis may cause loss of muscle tonus Muscle 
and diminution of palpable contractions or visible peristalsis. The 
degree of dilatation may be determined by inflation and ausculta- 
tory percussion, palpating the stomach tube in situ, fluoroscopy, trans- 
illumination, the gyromele, etc. (seep. 235). Changes of note corresponding 
to changes of posture may be evident as in pulmonary cavities if fluid 
be present. Succussionis of course constant in marked ectasia. Resid- 
ual contents in marked quantity, varying with the degree of stenosis 
and ectasia, are found in the fasting stomach even though the Reigel 
dinner be taken the preceding evening after lavage, and the contents 
are foul smelling (garlic or cabbage or hydrogen sulphide) and if placed 
in a fermentation tube with glucose (Einhorn's tube or an inverted 
test-tube) will within 24 or 48 hours show at least 2V volume of dis- 
placement by gas and the development of yeast plants. Indeed fission 
fungi will abound if fermentation be present, and indicate persistent 
stasis. 

Pain and Vomiting. — Pain is variable, often absent save in slight 
degree, or is substituted by extreme distension and oppression. The 
vomitus is as above described, frothy, of excessive quantity and often 
contains remnants of several previous meals, especially seeds and the like. 
It frequently separates into three layers on standing and is bitter and 
foul to the taste. The total acidity is increased by fermentation acids a fid 
the microscope shows in benign cases the yeasts and sarcince; in cancer, 
the Boas-Oppler bacilli. The fatty acids may be present by chemical 
and microscopic tests, the urine is scant, concentrated if vomiting be Urine 
profuse, and if gastric acidity be high is often alkaline in reaction. The 
persistent presence of bile in quantity invariably points to duodenal 
stenosis. 

Complications.— Acute autointoxication occasionally occurs ami 
even coma may result. Extreme distension may not only produce 
dyspepsia, bradycardia or palpitation but may seriously endanger a 
weak heart. Gastro-succorrhcea is common and, finally, that rare ami 



Distension. 
Vomitus. 



Acidi 



Autointoxi- 
cation. 



260 



MEDICAL DIAGNOSIS. 



Distinctive 
signs of 
stasis. 



Benign 
vs. 
Malignant. 



Usually 
secondary 



interesting condition known as gastric tetany may supervene, during 
the passage of a stomach tube, vomiting, or even percussion. 

Differentiation. — The clinical distinction between these various 
forms rests primarily upon the evidence of delayed emptying of the 
stomach and the presence and degree of stasis as indicated by persistent 
retention of food residue and fermentative changes. Furthermore in 
actual mechanical obstruction recurrent and copious vomiting, showing 
persistent and often ancient food residue, marked visible or palpable 
peristalsis and usually the presence of a pyloric tumor assist the diag- 
nosis. In stenotic insufficiency, moreover, we are ordinarily dealing 
with carcinoma, more rarely with pyloric ulcer or its scars, and the 
gastric contents will vary with the causative factors. 

As between the benign and malignant cases great difficulties may arise 
in diagnosis but in general it may be said that, while marked stasis 
characterizes both, the presence of large numbers of the Boas-Oppler 
bacilli, the cachexia, profound anaemia and the entire absence of hydro- 
chloric acid, free and combined, so nearly constant in cancer, are absent 
or present in less degree in benign stenosis, in which moreover, the 
sarcinae are present in large numbers. 

Gastroptosis. — The general topic of enteroptosis (p. 287) covers this 
condition of which it is a part. Gastroptosis may exist with or without 
dilatation, and may be symptomless or assume the character of neuras- 
thenia and nervous dyspepsia, or, motor insufficiency, though the latter 
is rare save in the severer forms. Amongst the commoner symptoms 
are:— subjective distension, troublesome borborygmi especially if 
tight clothing or bands are worn, tenderness over the solar plexus, 
subjective aortic pulsation and, in the presence of movable kidney, a 
dragging sensation or dull pain referred to the region of the sacro-iliac 
joint or lower lumbar region. Succussion is often present and low in site. 
The displacement is detected by the low position of the lesser curvature 
readily determined by inflation, as is any coincident dilatation. 

HOUR-GLASS CONTRACTION (bilocidar stomach) .—This rare 
deformity if not congenital, results usually from the healing of a 
large annular ulcer, more rarely from adhesions or scirrhus. The 
stomach is divided into two lateral segments and the communicating 
opening may be relatively large or very small. The symptoms vary 
with the cause and may closely simulate pyloric stenosis if the open- 
ing be small. 

Diagnosis.— Inflation alone will rarely make the diagnosis. The 
I following signs are valuable: — (1). The return of only the major por- 



DISEASES OF THE ABDOMINAL ORGANS — GASTRITIS. 261 



tion of a litre of water introduced by the tube. (2). In distension by Sisrnsdis- 

. tinctive. 

air or liquid, if the opening is narrow (a) the bulging and dull percussion 
note may at first be only in the cardial pouch and later be apparent 
in the pyloric portion, (b). The water or gas may be heard or felt 
to pass through the narrow orifice especially if pressure be applied. 
(c). Transillumination or fluoroscopy (bismuth and porridge method; 
will show only the cardial pouch, (d). If all recoverable water be 
withdrawn succussion will be evident only over the pyloric loculus. 

ACUTE GASTRITIS (gastritis glandularis acuta, acute gastric 
catarrh, phlegmonous gastritis). — Definition. — An acute (simple, toxic, 
or phlegmonous) inflammation of the gastric mucosa. 

Etiology. — Indiscretion in diet, nervous shock, toxic irritants such as 
ptomaines or arsenic, alcohol, mercuric chloride and potassium cyanide, 
or, if phlegmonous, pyaemia, septicaemia, the exanthemata, and rarely 
direct infection. It is most frequent at the extremes of life and in those 
debilitated and dyspeptic. Excessively hot or cold drinks, overeating 
and imperfect mastication are important factors. 

Morbid Anatomy. — The lesions vary from a simple catarrhal inflam- 
mation to necrosis and single or multiple abscesses. 

Symptoms. — Mere subjective weight or fullness, anorexia, and, a 
coated tongue with or without nausea, slight pain and general dyspeptic Severity 
manifestations may be the only symptoms. In the severer forms one finds 
headache, epigastric pain, nausea, vomiting and constipation or diarrhoea, 
complete anorexia, excessive thirst and a burning sensation. In the 
toxic forms, prostration is extreme, the pulse feeble, the surface cold, 
the case tending to coma and death. Such cases may occur in myas- 
thenia and stenotic ectasia. 

Stomach Contents. — Mucus is present in the vomitus, associated 
with blood and shreds of mucous membrane in the toxic forms and 
perhaps pus in the phlegmonous forms. Free HC1 is usually absent. 

Prognosis. — Recovery is prompt save in exceptionally severe toxic 
or phlegmonous cases. 

CHRONIC GASTRIC CATARRH (chronic gastritis). A chronic 
catarrhal inflammation of the gastric mucosa. Etiology.— The disease Usuall 
may follow an acute gastritis, but is more frequently associated with a 
monotonous or improper dietary, chronic diseases of the heart, liver. 
kidneys and lungs, gout, diabetes and the anaemias, excessive smoking 
and drinking, the use of highly spiced dishes, rapid and excessive 
eating and imperfect mastication. It follows certain infectious fevers 
as typhoid, cholera, yellow fever and the exanthemata, and. lastly, ulcer, 



secondary. 



Primary 

lesions 

dominate. 



- 



262 



MEDICAL DIAGNOSIS. 



Common 
signs. 



Limita- 
tions. 



cancer or dilatation of the stomach itself. It follows that certain com- 
plicating cases are hardly distinguishable as such. 

Symptoms. — Amongst the commoner are: — flatulence, belching, 
morning-malaise, nausea and perhaps vomiting, pyrosis, foul taste in 
the mouth, vertigo, palpitation, dyspnoea, cough and a poor or variable 
appetite often associated with a sense of repletion after even a light 
meal. Morning vomiting occurs especially in the chronic gastritis 
associated with hepatic cirrhosis ("drunkards' catarrh"). Consti- 
pation in some cases alternating with diarrhoea is the rule, there 
are usually evidences of a poor circulation, the tongue is coated and 
marginally indented by the teeth, and, nervous irritability is common. 
Marked loss of weight is seldom seen save in distinctly secondary cases, 
where it is usually due to the primary cause. 

Stomach Contents. — In advanced cases free HCl is diminished or 
absent, total acidity below normal, total stomach content usually increased, 
mucus abundant even in the empty stomach, and the digestive ferments 
diminished. 

Differential Diagnosis. — All differential diagnosis in diseases of 
the stomach is subject to limitations and exceptions, it being often 
impossible to draw hard and fast lines, and chronic gastritis must like 
all others be encountered in its early and complicating forms, lacking 
in the one case its most characteristic symptoms and in the other blending 
with or overshadowed by the primary disease. A chronic gastritis lacks 
the severe pain, extreme localized tenderness, hcematemesis and high HCl 
values of ulcer and the marked emaciation, lactic acid, Boas-Oppler 
bacilli and tumor so generally present in cancer. Achylia gastrica lacks 
both HCl and ferments, and, in the neuroses, the neurasthenic or hysteric 
symptoms, the more trifling or unlike disturbances of gastric secretion 
and the absence of an excess of mucus usually differentiate it. 

Prognosis. — Varies according to the cause. Many cases may be 
entirely cured, others never. 

GASTRIC ULCER.— Definition.— An ulcer of the gastric mucous 
membrane, usually single but often multiple and tending to perfor- 
ation. 

Etiology. — Aside from direct irritation or traumatism hyperacidity 
and antecedent ansemia appear to be the most important primary 
factors, but the true cause is not known* Sex. About 60% of the 



* Recent investigations indicate the existence in the normal stomach of 
protective anti-enzymes but under what conditions their activity fails is as 
yet unknown. 






DISEASES OF THE ABDOMINAL ORGANS — ULCER. 



263 



cases appear in females. Age. It occurs most commonly between the 
ages of 20-40, least often in children and elderly persons, and, there is 
probably no hereditary element. Occupation. Direct injury as from 
blows, tight lacing, pressure; the ingestion of corrosive drugs and such 
occupations as lead to anaemia, irregular or hasty eating and the use 
of improper food are important factors. 

Varieties. — (a). Common form, of pronounced and definite symp- 
tomatology denominated by Welch "gastralgic-dyspeptic." (b). The 
latent forms. Single or multiple ulcers may exist for years and perfor- 
ate or spontaneously heal without localized symptoms. (Probably 50% 
of ulcers are unrecognized clinically.) (c). The acute perforating form. 
In this there is a rapid advance and perforation and death may occur 
with few or no premonitory local symptoms, (d). The acute hemor- 
rhagic form. In this the symptoms are usually vague, of brief duration 
or may be entirely absent until profuse hemorrhage occurs.* Other 
types occasionally given are apparently unimportant. 

Pathology and Morbid Anatomy. — The ulcers vary in size from 
mere erosion to necrotic areas measuring from 4 to 6 inches in diameter. 
They are ordinarily small, \ to f in. round, and clear cut with little or 
no induration of the base or the margins, though if chronic they may be 
irregular or sinuous with terraced sides and marked infiltration. They 
are ordinarily single, not infrequently there are from three to five, 
very rarely a score or more. Location. Ulcer commonly occurs on the 
posterior aspect of the pyloric end of the stomach near the lesser 
curvature, from 10-15% are found at the pylorus.f and these if chronic 
may lead to pyloric obstruction and gastric dilatation. They are rare 
at the cardia and greater curvature. Gastric ulcers show a marked 
tendency to recur, usually within an old scar of a healed ulcer, and in 
an old ulcer base true carcinoma may develop. Healing. They heal 
by granulation and in cases of extensive ulcer may produce deformity 
such as the hour-glass contraction but more commonly a pyloric stenosis. 
Perforation. Perforation may result in general peritonitis demanding 
surgical interference and tending to a fatal termination, or, adhesions 
may form limiting the spread of the infection and saving the life. Many 
such cases of perforation go unrecognized, the omentum, liver and gall- 

* In one such case coming under the author's observation a young girl 
who had not had even a symptom of dyspepsia was seized suddenly with so 
profuse a hemorrhage as to cause collapse and cover the floor of a small 
kitchen with a layer of bright arterial blood. 

fMayo's figures (75%) are of course those oi a surgical clinic to which 
this type would naturally drift. 



Young 

fcmiilcs 
chiefly. 



Often 
overlooked. 



Treacher- 
ous types. 



Usually- 
single. 



Rare at 
cardia. 



Recur- 
rence. 



Self 

limitation. 



-. 



264 



MEDICAL DIAGNOSIS. 



Obscure 

abscesses. 



Fallacious 
figures. 



Larval 
cases. 



bladder and the pancreas may be involved, and, such adhesions com- 
Misinter- plicate a clinical picture and lead to mistaken diagnosis. The author 
pretation. ^ k serve( } cases [ n w hich the gall-bladder was involved, the symptoms 
exactly simulating gall stones. The acute perforations are usually 
direct and involve the general peritoneal cavity. Obscure abscesses 
may result in the chronic forms, subphrenic abscess and pyopneumo- 
thorax being sometimes observed and fistulous communication may involve 
tracts far distant from the original seat of trouble. The frequency 
of perforation as usually stated (13 to 18%) is certainly too high, being 
necessarily based upon cases yielding positive symptoms or coming to 
autopsy, and of course omitting the doubtful or larval cases which, 
no doubt, outnumber the others. 

Diagnosis. — The diagnosis of gastric ulcer still largely depends upon 
the concurrence of the old tetrad of symptoms, pain, localized tenderness, 
vomiting and hemorrhage, yet in many instances we meet and recog- 
nize early, latent, or larval cases which lack these franker symptoms.* 
A large proportion demand the careful balancing and analysis of a 
large number of factors and fatal perforation or hemorrhage may occur 
in cases which have previously lacked the symptoms necessary to even 
a tentative diagnosis. Placing the determining factors somewhat in 
the order of their clinical importance we have (a). Pain. (b). Local- 
ized tenderness, (c). Hemorrhage, (d). Vomiting, (e). High hydro- 
chloric acid values, (f). General dyspeptic symptoms, (g). Anamia. 
(h). Age. (i). Sex. (j). Occupation. 

(a). Pain. The characteristics of the pain of gastric ulcer are 
(1st). Its intermittent and paroxysmal nature, and its relation to 
the taking of food and to special forms of ingesta. (2nd). Its 
time of occurrence. Being dependent' primarily and chiefly upon 
the increased secretion of hydrochloric acid incident to the digest- 
ive process, it is not as a rule immediate but usually becomes 
severe and even cramp like in from half an hour to two hours 
after eating and continues until the stomach is emptied by vomiting, 
stomach washing, or by the natural mechanism. In some instances 
distress almost immediately following the ingestion of very hot, cold 
or acid substances is significant. Only in exceptional cases, namely 
those of continuous hypersecretion do we find persistent pain of a duller 
character between meals and especially at night. This fact suggests 
the importance of stretching and distension as well as peristalsis in 
the production of crises. The location of the pain necessarily varies 
* The disease is often one of extremely slow and insidious development. 



Important 
factors. 



Character- 
istics. 



Cause. 



Incidence. 
Duration. 



Helpful 
sign. 

Persistent 
pain. 



DISEASES OF THE ABDOMINAL ORGANS — ULCER. 



265 



somewhat with the position of the ulcer and of the stomach itself, being 
as a rule lower in tightly laced women and in cases of ectasia than under 
ordinary conditions. As five-sixths of the stomach lies to the left of 
the linea-alba, and most ulcers are upon the lesser curvature, one usually 
finds the pain at, or, more commonly, just to the left of the median line 
between the ensijorm and the umbilicus, usually near the former. The pain 
itself varies greatly in character and degree. In its typical form it is a bor- 
ing deep seated pain, but is also described as burning, stabbing, cutting or 
cramp-like, quite frequently felt at the back, sometimes radiating upwards 
to the region of the shoulder blades. This typical pain is often replaced 
by that of a duller character and a suggestive feature when present is 
the relief accompanying changes in attitude both in the presence and 
absence of adhesions. Increase of pain in recumbency suggests but 
does not prove a lesion of the posterior wall, and a similar inference 
applies to the lateral or prone positions as regards a lesion of the pylorus 
or anterior wall. Localized tenderness. The importance of this 
sign lies in the fact that a distinctly circumscribed superficial or deep 
tenderness, often extreme, is usually present and corresponds closely 
to the area of maximum pain. It is usually epigastric but is a trifle 
to the left of the median line and localized as contrasted with the tender- 
ness of gastric hyperesthesia which is diffused over the whole outline 
of even the inflated stomach. About | of the cases show a sharply 
localized area of superficial or deep dorsal tenderness, often extreme, 
slightly to the left of the lower dorsal spines (3-4 cm.)*. 

Hemorrhage. — Hemorrhage which occurs in | to § of recognizedulcers 
is, if large, always associated with vomiting and is easily recognized 
as of gastric origin; but the smaller hemorrhages rapidly undergo such 
digestive changes as to closely simulate the small dark clots or coffee 
ground particles of carcinoma. Furthermore, severe or even fatal 
haematemesis may be due to gastric erosion or hepatic cirrhosis as well 
as ulcer. The stools as well as the stomach contents should be carefully 
investigated before declaring hemorrhage absent and concurrent symp- 
toms be carefully weighed before a frank hemorrhage is ascribed to 
ulceration. Enormous hemorrhage may be recovered from and but a 
small number die directly from it. Vomiting. Though often coincident 
with a painful crisis vomiting with or without hemorrhage is far 
from constant and nausea is more often seen. If present, it is usually 
irregular and in any event relieves or modifies the pain. 

* Rarely it is bilateral or on the right side alone. A second /.one may be 
found occasionally at the level of the fourth and fifth dorsal spines. 



Important 
points. 



Referred 
pain. 



Posture. 



Usually 
present. 

Site. 



Spinal 
areas. 



Usually 

evident. 



Disturbing 
factors. 



Caution. 



Inconstant. 



266 



MEDICAL DIAGNOSIS. 



Ilyper- 
chlorhydria 

vs. 
Hypochlor- 
hydria. 



Rapid 
digestion. 



Intractable 
type im- 
portant. 



Tentative 
diagnoses. 



Hyperacidity. — High hydrochloric acid values are common (30-45%), 
normal values probably the ride, subacidity the exception.* As hyper- 
chlorhydria is a common condition without ulcer, so that the symptom 
while important is only corroborative, nevertheless decided hypoacidity 
goes far to exclude ulcer, and lactic acid is almost invariably absent. 
(Subacidity is usually associated with complicating catarrhal gastritis or 
ectasia.) The vomiting in hyperacidity is sharply acid to the patient's 
taste, and it must be remembered that the proper determination of 
high hydrochloric values should be based upon a test dinner rather than 
the meagre test breakfast and that the sound must not be used if violent 
retching be induced nor shortly after a hemorrhage. If vomiting be 
present a proper test meal may be taken and thus recovered, the interval 
being often sufficiently well observed. 

General Dyspeptic Symptoms. — These are more commonly asso- 
ciated with varying degrees of actual pain than is usual in other 
ailments Because of normal or high acidity the digestion is normal 
or often more rapid than normal, the tongue relatively clean and the 
appetite often good. Indeed true anorexia is an exceptional symptom 
in gastric ulcer, insufficient nutrition being ordinarily dependent upon 
the patient's dread of the pain and distress attending the ingestion of 
food. Anaemia. The author feels that too little stress is laid by 
writers upon the frequency of intractable ancemia and regards it as one 
of the more important of the subordinate factors in diagnosis. It is 
probable that the anaemia of gastric ulcer in some cases antedates the 
lesion, probably invites, and, tends to perpetuate it. In others as the 
result of persistent or recurrent hemorrhage of varying degree, it as- 
sumes an intractable though not extreme secondary type whether 
antecedent or consequent. Marked intractable ancemia of the secondary 
type in young persons associated with gastric disturbance and normal or 
high acidity is suggestive, and, when accompanied by even minor 
degrees of persistent local pain and tenderness will justify the institu- 
tion of medical treatment under a tentative diagnosis. 

Differential Diagnosis. — Simple hyperacidity is commonly tempo- 
rary, intermittent, dependent upon known etiologic factors and usually 
lacks severe pain, localized tenderness and hemorrhage.! Gastric 
hyperesthesia not only involves the whole stomach outline but is asso- 

* According to many observers it is a more constant symptom in the 
United States than in European clinics, the average total acidity being above 
100 and the free acid above 50. 

t Rare instances of vicarious menstruation with hyperacidity occur. 



> 



DISEASES OF THE ABDOMINAL ORGANS — ULCER. 



267 



ciated with distinctive neurotic symptoms. Gastric erosions offer great 
difficulty in many instances but are in general to be distinguished 
by a more diffuse burning sensation upon the taking of food, actual 
pain being as a rule slight or absent, or in any event coming on 
immediately or within half an hour of the ingestion of food. Pressure 
tenderness is usually lacking and hyperacidity is the exception. The 
wash water of the fasting stomach contains shreds of mucous membrane, 
but this may occur in other conditions. Finally, it may be said that 
inasmuch as a case of erosion demands much the same treatment as 
ulcer if recognized, it is not necessary to weigh too carefully those 
differential points which must, the writer believes, be taken cum grano 
salis, the points of distinction being in many instances less definite and 
absolute than are here laid down. 

Duodenal Ulcer. — This condition, obscure and frequently over- 
looked, is suggested by the symptoms of ulcer attended by maximum 
pain to the right of the median line, with absence of blood in the vomitus 
or stomach washings and frequently its presence in the stools. Hyper- 
acidity is the exception in duodenal ulcer, slight jaundice is not uncom- 
mon and the pain accompanying the taking of food usually becomes 
severe only after two or three hours. As between ulcer of the pylorus 
and one of the duodenum an absolute diagnosis is usually impossible. 
Carcinoma of the stomach presents little difficulty save in the rare sub- 
acid ulcer cases or those in which a carcinoma develops upon an old 
ulcer base, in which case the symptoms of ulcer at first predominate 
and are gradually submerged in those of carcinoma* The pain of 
cancer is ordinarily less sharp and paroxysmal, more continuous, the 
superficial or deep tenderness less in degree. A palpable tumor makes 
its appearance in a large majority of the cases and is usually right 
sided, solid and firm, whereas in ulcer, save in pyloric cases or where 
adhesion and perforation have occurred, if any tumor is felt on the wall 
it is thin and disc-like representing the inflamed ulcer base, and usually 
left sided. The nutrition suffers greatly in carcinoma and is associ- 
ated with the progressive development of the well known cachectic 
appearance and morose facies. Hemorrhage is more consistently of the 
oozing type, appearing as "coffee ground" detritus in the vomitus and 
stomach washings, the location of the pain is usually to the right o\ the 
median line, because of the predominance of rancors at the pylorus 



May be 

clear. 



Often 
obscure. 



Pain. 

Blood in 
stools. 



Puzzling 
cases. 



Usually 
clear. 



Marked 
differences. 



* It is evident thai these arc at certain periods undiagnosticable, yel 
repeated examinations will show the gradual and significant transition. See 
note, ]> 271. 



J 



r 



268 



MEDICAL DIAGNOSIS. 



Dragging. 



Basis of 
diagnosis. 



Proper 
procedure. 



A bad 
custom 



Vulnera- 
bility of 
mucosa. 



and finally and most conclusively an analysis of the stomach contents 
reveals with rare exceptions an absence of free hydrochloric acid, the 
presence of lactic acid and in a majority of instances the Boas-Oppler 
bacillus which is differentiated from the mouth bacillus of a similar 
type by staining a mount with Gram's solution, which colors the 
Boas-Oppler brown and its impersonator blue. 

ULCER WITH ADHESIONS.— The diagnosis of ulcer with adhe- 
sions depends largely upon the general symptoms of ulcer as stated, com- 
bined with those referred to adjacent organs and, sometimes, a sensation 
of dragging or pulling experienced in certain movements or attitudes. 
Very often a tumor may be palpated but many cases offer none but 
indefinite or misleading signs. Perforation. The symptoms of per- 
foration are those of surgical shock succeeded by symptoms of local or 
general peritonitis and occurring in cases ordinarily giving a history oj 
ulcer. They are essentially surgical and need not be further considered. 
It is evident that gastric ulcer is not a single symptom disease, but one that 
often requires a careful estimate of probabilities, and a thorough knowl- 
edge of all of the diagnostic factors involved. No doubt an immense 
number are overlooked and go on to spontaneous healing, certainly many 
die of sudden hemorrhage or perforation without previous recognition. 
Having these facts in mind, the author believes that wherever any 
reasonable probability exists that a given case is one of ulcer, the phys- 
ician should not wait for more light but should at once institute appro- 
priate medical treatment. 

Operative Cases. — The tendency to perform radical surgical opera- 
tions of the major type as a primary measure in gastric ulcer is to be 
deplored, and many such cases are undoubtedly those of simple erosion. 
Nearly every case even of true ulcer should first receive prolonged medical 
treatment and the knife be reserved for the obstinate and recurrent, per- 
sistently hemorrhagic, or perforative cases, for those associated with 
adhesions which tend to impair the health or persistently annoy the 
patient, or, for actual stenosis. 

GASTRIC EROSIONS.— Under various conditions and influences 
both local and remote the gastric mucous membrane may show a sur- 
prising vulnerability, and erosions are easily produced varying from 
a pin's head to the size of a lentil. Various names have been given 
to this condition and Einhorn has described it as a separate disease, 
but in view of the fact that it may occur under purely nervous influ- 
ences, in chronic gastritis, achylia gastrica, and probably as an early 
stage of gastric ulcer, it should hardly as yet be dignified to that extent. 



DISEASES OF THE ABDOMINAL ORGANS— CANCER. 



269 



Symptoms. — These may closely simulate gastric ulcer with con- 
siderable or small hemorrhages and be entirely symptomless or blend 
with the symptom complex of the various diseases above mentioned. 
In those cases simulating ulcer the pain is usually less intense, and 
comes on earlier but may continue until the stomach is empty. Stomach 
washings show tiny shreds of membrane, local tenderness is not marked 
and mucus is usually present in the vomitus or removed contents. 
Diminution of hydrochloric acid is the rule. Occult blood in the feces 
and slight staining of the stomach washing are common. Under proper 
treatment recovery is usually prompt. 

Comment. — Differential diagnosis is important only as preventing 
unnecessary operations as the medical treatment of the two conditions 
is almost identical. 

CARCINOMA.— Etiology. — Predisposing Causes. 50% of all 
cases of carcinoma in the male are gastric and age markedly affects 
the ratio of incidence. Such growths are rare under 30, but are always 
possible.* It is most frequent in males, and heredity is a factor of 
considerable importance. The scar of a pre-existing gastric ulcer occa- 
sionally undergoes malignant change. Traumatism seems in rare 
instances to be a factor and some authorities lay much stress on \ 
mental worry or strain, but it is probable that these conditions exercise 
little influence. 

Morbid Anatomy. — Cancer of the stomach is usually primary, 
though occasionally it is secondary to cancer of the breast, uterus 
or other organs. The most common growth is the cylindrical celled 
adeno-carcinoma. Encephaloid is next in frequency, then scirrhus 
and colloid. Malignant growths of the stomach are frequently the 
source of metastases in their advanced stages. Such tumors usually 
develop near the orifices and most commonly at or near the pylorus 
(50%). In this situation they tend to cause obstruction and dilatation. 
Growths at the cardia (9%) are often associated with atrophy and 
occasionally marked esophageal distension. The stomach may be 
greatly displaced as well as dilatated in the case of pyloric growths 
and adhesions may obscure and complicate the clinical picture. Such 
tumors are ordinarily, however, freely movable and may in rare instances 
be found in almost any part of the right half of the abdomen. 

* The author recalls a serious blunder due to the fact that the extreme 
youth of the patient made him loath to accept what should have been posi- 
tive evidence of malignant growth; nevertheless, the disease is rare under 
the age of 30, uncommon between the ages of 30 ami 40, most frequent 
between the apes of 40 and 70. 



Occult 
blood. 



Incidence. 



Causes 

unknown. 



Usually 
primary. 



Types 
Sites. 



Dislocation 

and ad- 
hesion. 



270 



MEDICAL DIAGNOSIS. 



Seldom 
severe. 



Usually 
moderate. 



May be 
extreme. 



Common. 



Indican 
and diazo. 



Peculiar. 



Constant 
symptoms. 



Frequent. 
Stools. 



Coffee 
grounds. 



Wasting. 



Symptoms. — Cases may reach an advanced stage of development 
without producing any recognizable symptoms save those made evi- 
dent by examination of the stomach contents. Ordinarily one finds: — 
(a). Dyspepsia. Eructations, pressure, heavily coated tongue, foul taste 
in mouth, etc. (b). Progressive loss of weight, (c). Marked progressive 
impairment of strength and endurance, (d). Pain. Usually dull, 
boring and somewhat persistent. This symptom is present in 90% of 
all cases, is usually epigastric but may be referred, especially if adhe- 
sions exist, or if the stomach is greatly displaced and, in rare instances, 
may be severe and spasmodic. Tenderness may or may not be pres- 
ent and is usually not extreme. It is most marked in the right epigas- 
trium and may be associated with tenderness in the lower dorsal region, 
posteriorly, or, anteriorly, at various points between the nipple and 
the umbilicus, (e). Anamia. At first moderate, this may later become 
extreme, usually preserving a definite secondary type (see anaemia), but 
in advanced ulcerative cases showing at times extreme grades closely 
simulating that of atrophic gastritis or pernicious anaemia. Leucocy- 
tosis is usually present in metastasis or rapid ulceration, (f). Fever. 
50% of the advanced cases are accompanied by a moderate fever of the 
hectic type, in rare instances associated with "chill and fever," due prob- 
ably, to septic absorption from an ulcerating surface, (g). Urinary 
signs. The only important urinary findings are indicanuria, which is 
usually present to a marked degree, and, the diazo-reaction, as reported 
by the author in certain advanced cases, (h). Cardiac weakness. 
Marked cardiac weakness and edema of the lower extremities are 
usually terminal symptoms, (i). Anorexia. This is usually marked 
and often associated with repugnance, especially towards red meat, 
(j). Nausea. This is present in a great majority of the cases, (k). 
Vomiting. A symptom present in 90% of the pyloric cases and 
occurring usually one or more hours after meals. It is ordinarily 
occasional, but may be frequent or very rarely almost continuous, tend- 
ing to rapid exhaustion and death. (1). Hemorrhage. In from 20 to 
30% there is recognizable hemorrhage and it undoubtedly occurs in 
I a much larger portion. In all cases of suspected cancer of the stomach, 
the stools should be examined as well as the vomitus and stomach 
contents. Bright red arterial blood in the vomitus is unusual, it being 
ordinarily in small dark grumous clots or "coffee ground" particles, 
because of the action of the digestive juices, (m). Cachexia. In 
advanced cases the skin is pale, yellow, inelastic and ill fitting because 
of malnutrition and loss of weight, and often shows areas of pig- 



DISEASES OF THE ABDOMINAL ORGANS — TUMORS. 271 

mentation or pigment atrophy. A curious earthy pallor is often present Pallor. 
and is more or less characteristic, and, quite as striking is the peculiar 
facial expression so often encountered in these cases the patient 
appearing saturnine, anxious and depressed, (n). Tumor. A palpable 
tumor may be found in about 80% of the cases, may occupy 
almost any position and be freely movable or attached by adhesions. Location. 
Osier has reported several cases in which a faulty diagnosis was originally 
made and every clinician can recall like instances. Unless fixed by Source of 
adhesion such tumors are more or less movable in respiration. The 
liver should in all cases be carefully examined for the presence of metas- 
tatic nodules. 

Stomach Contents. — To obtain the stomach contents one should 
thoroughly wash out the stomach in the evening, giving a test breakfast 
in the morning, and should use a Boas test meal (see page 238). The 
preliminary washing may show an excessive quantity of fluid or give (jeneral 

• 1 • r t • • 1 -t ii-i findings. 

evidence of imperfect digestion, impaired motility and pyloric obstruc- 
tion (stasis).* On the other hand pyloric incontinence or duodenal 
stenosis may be indicated by the persistence of large quantities of 
bile. 

Chemical Findings. — Hydrochloric acid is seldom present and then 
not in any considerable quantity. It is probable that most of the cases 
in which free hydrochloric acid is found have their origin in an old 
ulcer base or scar.f The ferments are either entirely absent or greatly 
reduced, lactic acid is usually present and motility and absorption Lactic acid, 
are greatly diminished. J 

Microscopic Findings. — The microscope may reveal fragments of 
growths and evidences of hemorrhage, the Boas-Oppler bacillus, and, i'>oa>- 
absence or sparseness of yeast fungi or sarcinae. bacillus. 

Differential Diagnosis. — The following facts should be borne in 
mind, viz., that in chronic gastritis, the hydrochloric acid may be dimin- 
ished or absent and the ferments more or less inactive, but in this dis- 
ease lactic acid is not present, pain is absent or slight, hemorrhage does not 

* Substances are sometimes retained for many days as was the case with 
a segment of orange brought in by a patient under the impression that it 
was a cyst, the acid of the gastric juice having completely changed the 
appearance of the undigested food. 

yB. Moore, Lancet, p. 1121, 1905. reports gastric subacidity or anacidity 
in two-thirds of all cases ol cancer affecting other organs. 

t Estimation of the albumin contained in the normal saline solution used 
for washing the previously emptied and washed stomach involves too much 
handling as it is present only in ulcerating carcinomata or occasionally in 
gastric ulcer. 



Chronic 
gastritis. 



272 



MEDICAL DIAGNOSIS. 



Achylia 
gastrica. 



Ulcer. 



Tabes. 



Variation; 



Important 
data. 



occur except in connection with cirrhosis of the liver, emaciation is 
seldom as early, progressive or extreme and, a tumor is not to be found. 
In achylia gastrica all findings are negative, hydrochloric acid, lactic 
acid and the ferments are absent, there is usually no pain or hemorrhage 
and never tumor. Emaciation is usually not marked or progressive, 
though occasional exceptions occur. In gastric ulcer, hydrochloric acid 
is usually normal or in excess, lactic acid is absent, ferments are normal, 
emaciation is ordinarily slight and a tumor is absent save in the rarer 
instance when one may feel the inflamed base of an ulcer, a thickened 
pylorus or a mass of adhesions which may have resulted. Ulcer has 
only pain and hemorrhage in common with carcinoma, its hemorrhage 
is usually arterial, its pain more paroxysmal, directly related to the 
taking of food, and usually, markedly or completely relieved by emptying 
the stomach or by the ingestion of bicarbonate of soda. Cancer occurs 
in the old, ulcer more frequently in the young. Finally, the diagnosis 
of cancer must rest chiefly upon the presence of lactic acid after a Boas 
test meal, evidence of hemorrhage, the Boas-Oppler bacillus, early and 
progressive loss of strength, emaciation, and, tumor. 

GASTRIC CRISES. — Lightning like attacks of agonizing, cramping, 
epigastric pain, associated with nausea or violent vomiting, at first of but 
a few minutes' duration, later persisting for hours or days, separated 
at first by long intervals, but progressively increasing until for a period 
of weeks they may occur daily, are characteristic of tabes dorsalis in 
most instances* and may constitute the first symptom. The recession 
is usually as abrupt as the onset, but unusual cases are encountered in 
which pain is absent, or, the critical termination may be replaced by slow 
tedious improvement. Intestinal and rectal crises of much the same 
type also occur. As an early symptom it is rare but important and ex- 
tremely difficult to determine in the absence of tabetic symptoms because 
of its resemblance to many other conditions. A history of syphilis and 
the increasing frequency and duration of the attacks combined with 
their dramatic suddenness of onset and recession are valuable factors 
in differential diagnosis. 

ARTERIOSCLEROTIC ABDOMINAL CRISES.— Frequent 
attacks of severe paroxysmal pain of brief duration (15-30 minutes) 
induced by exertion or emotion and frequently by the recumbent posi- 
tion, if occurring in men past forty suggest arterio-sclerosis. The 
aortic region is usually tender and another type is associated with true 

* Similar crises may be encountered in developed spinal paralysis, mul- 
tiple sclerosis, morphinism, lead colic, etc. 



X 



DISEASES OF THE ABDOMINAL ORGANS — SYPHILIS. 



2 73 



Not excess- 
ively rare. 



angina pectoris. The attacks may show the same tendency to progress 
over a period of many years as is the case in tabetic crises but are 
more frequent, less sudden in onset and recession and lack the gas- 
tric disturbance. The age, the presence of arterio -sclerosis, the lack of 
relation to meals or constant gastric findings should suffice to exclude 
ulcer. Max Buch claims that the relief afforded by diuretin 3-4 gms. 
and tincture of strophanthus 15 to 24 min. daily is of diagnostic 
importance* 

SYPHILIS OF THE STOMACH.— At the period of general infec- 
tion dyspeptic symptoms are not uncommon though usually inde- 
terminate or taking the form of hemorrhagic erosions due to spe- 
cific endarteritis. Gummata are by no means as uncommon as 
formerly supposed and clinically the syphilitic cases may resemble 
simple chronic gastric catarrh, ectasia, erosions, ulcer or carcinoma. 
Three particularly interesting cases have come under the author's 
observation. In one, an old gentleman of 70, there was a palpable i Three 
pyloric tumor, stenosis with marked dilatation, extreme gastric 
intolerance, tenderness and emaciation. The cause was suggested 
by Hutchinsonian teeth in a daughter. Another was a steeple 
climber formerly a sailor aet 35, who presented a flat but definite and 
exquisitely tender plaque in the left epigastrium and extreme paroxysmal 
pain. The 3rd was a young man .of 27 who presented the clinical 
symptoms of malignant pyloric stenosis. In all three specific medi- 
cation promptly relieved the pain and resulted in complete disappear- 
ance of all symptoms. Excessive pain and tenderness with signs of 
carcinoma were the prominent features and in all the evidence of past 
syphilis was directly or indirectly adequate. Coffee ground vomitus 
was present in the first and third. The first and second cases were 
remarkable because of the palpable tumors. 

TUBERCULOSIS OF THE STOMACH is so rare as a primary 
disease as to be a clinical curiosity. Secondary lesions are common 
in pulmonary tuberculosis. The signs of ulcer, the presence of the 
tubercle bacillus and the pre-existing disease in secondary cases make 
the diagnosis. 

CONGENITAL STENOSIS OF THE STOMACH.— This inter 
esting condition has been reported sufficiently often by reliable 
observers to entitle it to a definite place in clinical medicine. Its 
symptoms are vomiting, constipation, dilatation, increased peristalsis 

* In a case observed by the author the pain occurred both as an isolated 
epigastric crisis and in combination with typical angina pectoris. 

18 



274 



MEDICAL DIAGNOSIS. 



Line of 
inquiry. 



Remember 
stomach. 



Normal 
findings. 



Peculiar 
forms. 



and, in most instances, palpable tumor representing the thickened 
pylorus. In some instances a tumor has not been felt and in a recent 
case (McCaw and Campbell) the obstruction was apparently due to 
redundancy of the mucous membrane with obstructing folds. (See 
also p. 258.) 

DISEASES OF THE INTESTINES. 

LINES OF INVESTIGATION.— Careful inquiry should be made 
as to antecedent diseases, especially dysentery, typhoid fever and appen- 
dicitis and the latter often necessitates a careful cross examination 
covering the actual symptoms present in misnamed attacks. As in 
diseases of the stomach, the habits of the patient as regards smoking, 
drinking, meal hours, the time consumed at meals, character of the diet, 
and the condition of the teeth are important. 

THE FECES. — The character of the stools demands attention. 
Their consistence, size, number, form, quantity, color and the admix- 
ture of mucus or blood are the chief features. The presence of 
constipation, diarrhoea or pain and the relation of the two latter to 
meals or a fasting period should be thoroughly gone into. In making 
inquiry concerning constipation it is best to ask whether the bowels 
move daily without medicine. In the case of diarrhoea one should 
know whether it is nocturnal or diurnal and induced or increased by 
mental excitement or emotion. In certain forms the loose stool invari- 
ably follows a meal. Finally it should never be forgotten that the 
stomach may be at the bottom of the intestinal disturbance. (Late 
achylia gastrica and chronic gastric catarrh, hyperchlorhydria, etc.) 

Normally the stools consist of food remnants, epithelium, salts, 
bacteria and traces of the digestive fluids. The color depends upon 
the diet and is normally brown or brownish yellow, being darker on 
meat diet, light yellow on milk diet. Certain drugs as iron and bis- 
muth produce a black stool; senna, rhubarb, santonin and calomel a 
greenish yellow tint. In prolonged constipation and in certain forms 
of chronic obstruction, "goat droppings" balls, scybalae, or hardened 
masses grooved by intestinal folds may be encountered or, the pipe 
stem or ribbon like stools suggesting but not proving organic obstruc- 
tion in the lower bowel. On the other hand all grades of liquid or 
semi-liquid stools may be met with in the diarrhoeas; such as the 
so-called "pea soup" stool of early typhoid or the brilliant ochre liquid 
of the later stage and the peculiar rice water stools of true cholera and 
cholera nostras. 



DISEASES OF THE INTESTINES — EXAMINATION. 



275 



Blood, 

mucus 
and pus. 



Food Remnants. — Consist chiefly of undigested vegetable mat- 
ter, never, macroscopically, of meat save in the serious intestinal 
diseases. 

Blood from the lower bowel may be red or, if dark, is not usually 
coagulated; if from the stomach or upper bowel it presents a tarry 
appearance. Mucus may appear as a membrane, or as an envelope 
covering the stools, or mixed with the feces, the significance being that 
of intestinal catarrh. Pus if present proves a lesion of the lower bowel 
and fragments of tumor may yield information of value. Intestinal 
parasites are considered on page 494. 

Collecting the Specimen.— The simplest method consists in the 
use of one of the covered receptacles which can be placed within and 
rest upon the basin of a water closet or directly under the patient lying 
in bed. These can be procured with a removable wire screen which is Sieves. 
useful in washing the stools for concretions. As an emergency measure 
any receptacle may be used and for a sieve one may employ ordinary 
mosquito netting fastened to an extemporized hoop. 

Microscopic Examination. — The portion to be examined is pre- 
pared by adding a small amount of physiologic salt solution and a few 
drops of 1% formaline solution. Normally the appearance varies with 
the diet. In ordinary mixed diet there are various vegetable cells usu- 
ally characteristic, starch granules are ordinarily absent or if present are I 
readily demonstrated by a drop of Lugol's solution. Their presence is 
pathologic. Meat fibres in small numbers may be recognized as may Findings. 
elastic and connective tissue fibres. Oxalate of lime and fatty acid, 
calcium carbonate and calcium and ammonio-magnesium phosphate 
may be present in characteristic crystals. The Charcot-Leyden crys- 
tals occur in pulmonary tuberculosis, typhoid fever, dysentery, and, 
with intestinal parasites. Ruby red or orange yellow rhombic plates 
of hematoidin, or its amorphous forms, may be present in hemorrhage 
or severe catarrhs; fat may also be present as characteristic highly 
refracting globules and both fat and fatty acid crystals are increased 
in diseases of the liver or pancreas, and, in acute enteritis. 

Blood cells may be present if from the lower bowel and pus corpuscles 
if there be an ulcerative process or discharging abscess. Tumor frag- 
ments, mucin threads and the large variety of bacteria, most important 
of which pathologically is the bacterium coli commune and the tubercle 
bacillus. 

Schmidt's Method. — A formal and extended examination of the 
feces is ordinarily too exacting and time consuming for the general 



Technique. 



f9r>- 



276 



MEDICAL DIAGNOSIS. 



Simple. 



Method. 



Macro- 
scopic 

findings. 



Micro- 
scopic 
findings. 



Chemical 
findings. 



practitioner but one of the simplest methods is here given for the sake 
of completeness. 

Test Diet. — Schmidt suggests the following diet (as containing con- 
stant and sufficient calories, simple, and always obtainable), which has 
been slightly modified by many different observers, but represents the 
basis of all "normal" or test diets: 1.5 litres milk, 100 gm. zweiback, 
2 eggs, 50 gm. butter, 125 gm. very rare or raw beef, 190 gm. potatoes, 
and gruel from 60 gm. of oatmeal, and, 20 gm. sugar, or, as used by 
Steele: — Breakfast: 2 eggs, \ of the amount of toast and butter, 2* 
glasses of milk, oatmeal with milk and sugar. Dinner. The steak and 
potatoes, \ of the amount of toast and butter, i| glasses milk. Supper. 
2 glasses of milk, remainder of toast and butter, 1 or 2 eggs if desired. 

This need be given for only two or three days, a capsule (0.3) car- 
mine being given with the first meal. The appearance of the dye 
in the stool initiates the examination and serves to measure the time 
of passage. Schmidt than proceeds to determine consistence, color 
and odor and reduces the feces to a liquid form in a mortar with 
distilled water. The ordinary blacked plate or a Petri dish placed 
over a black background then facilitates the examination. Normally 
there should be nothing except the indigestible oatmeal hulls and 
sago-like particles of potato. Pathologically one finds:— (a). Mucus 
appearing as glassy flakes sometimes stained yellow, (b). Remnants 
of potato the resemblance of which to mucus may require the micro- 
scope to differentiate, (c). Remnants of muscle fibre indicating 
impaired intestinal ferments, absence of the enzyme (enterokinase) 
or abnormal motility, (d). Crystals of magnesium and ammonium 
phosphates indicating fermentation, (e). Connective tissue remnants 
differentiated from mucus by their, toughness, (f). Pus or blood, 
(g). Parasites, (h). Concretions, (i). Foreign bodies. 

The microscopic examination merely confirms and somewhat ampli- 
fies these findings. It is recommended that three mounts be made. 
(1). A drop of the prepared material. (2). Same + acetic acid. (3). 
Same as No. 1 + a drop of dilute Lugol's sol. (iodine 1., potas, iodide 2, 
water 50). No. 2 is heated to boiling before covering and upon cooling 
will show fatty acid crystals set free by the acetic acid ; if reheated these 
will form droplets. No. 3 shows the violet blue reaction of potato cells 
and certain spores. 

The chemical examination consists of 3 routine tests: — (1). The 
reaction obtained by dropping the prepared material into a few c.c. of 
dilute aqueous litmus sol. (2). The sublimate test. (Equal parts of 



DISEASES OF THE INTESTINES — TESTS. 277 



Lion. 



the prepared material and a sol. of mercuric chloride (25%; should 

strike a pinkish red color indicating hydrobilirub in.) Unchanged bile 

pigment yields a green color and is pathologic. (3). The fermentation i-crmenta- 

test. — 5 c.c. of formed feces, or its equivalent if liquid, are prepared with 

sterile water and poured into the bottle of Strasburger's instrument 

or better the simple and easily cleaned modification of Steele which 

can be made by any one.* 

The tube surmounting the bottle it filled with water, the parallel 
tube remaining empty; if kept at blood heat for 24 hours gas will rise 
and displace the water in the first tube forcing it into the outer parallel 
tube whose air finds an outlet through the longer inner tube; thus the 
amount of water displaced is a measure of the amount of gas formed. 
£ displacement is distinctly pathological. Albuminous putrefaction 
is indicated by a foul smell and alkaline reaction, carbohydrate 
fermentation by acidity. 

Inferences from the Tests.-— Color. A pink color reaction (test 
2) is normal, the green indicates increased motility. Absence of color 
a fat stool or absence of bile. Meat remnants. Whether muscle or 
connective tissue and even if microscopic, an excess of either is 
pathologic. In the case of connective tissue, deficient gastric digestion 
is indicated or excessive gastric motility. In the case of the muscle 
the digestive trouble is probably intestinal. An excess of fat merely 
indicates deficient digestion of that material but suggests hepatic pan- 
creatic or intestinal disease; fermentation means either poor starch 
digestion or intestinal disturbance. Albumin fermentation, either defi- 
cient gastric or intestinal digestion or increased motility. As a matter 
of fact it may be stated with regret that up to the present time the amount 
of information gained is too slight to compensate the busy practitioner 
for even the small amount of time necessarily consumed. Nothing 
but constant practice will suffice to establish proper standards represent- 
ing the normal and the abnormal. And finally, proteid fermentation 
is more easily estimated by testing for indoxyl. 

Concretions. — Enteroliths. Enteroliths originate usually in the small 

*The materials needed are— a large mouthed medium sized bottle earn- 
ing a rubber cork, perforated by a glass tube. Two test-tubes are prepared 
each having a rubber cork with two perforations. Both are Inverted and 
Connected by a U tube the extremities of which projeel slightly above the 
inner surface of the cork, one is then pressed down over the vertically pro- 
jecting tube of the bottle and holds the other tube parallel with it by virtue 
of the connecting U tube. Test-lube \'o. j is fitted with a small glass tube 

which goes nearly to the top and projects below. 



wm 



278 



MEDICAL DIAGNOSIS. 



Site. 
Etiology, 



Source of 
error. 



Appear- 
ance. 



Fecal 
masses. 



Tonus 



intestines, are small, light in color and ordinarily of no importance, 
consisting chiefly of magnesia and lime. Coproliths. These sausage 
shaped bodies are most frequent in the appendix, caecum, sacculations 
and rectum, rarely they attain considerable size and may cause obstruc- 
tion. Pancreatic calculi. These may be faceted or are, usually, rough 
and friable they contain no bile pigment and cholesterin and are sol- 
uble in chloroform. Biliary calculi. These occur as well known 
faceted bodies, or, if in the form of sand, may require chemical tests 
for their identification.* 

HEMORRHOIDS (piles). — This common condition, rare in children, 
most frequent in men, consists of a diffuse or circumscribed varicosity 
of the hemorrhoidal veins, either in the lower portion of the rectum 
(submucous) or at the anal margin (subcutaneous). The condition 
is induced by constipation, continuous standing or sitting (i.e. sedentary 
occupations), the habitual use of cathartics, pregnancy, the pressure 
of tumors, or obstructed portal circulation from whatever cause and is 
favored by the lack of valves in the hemorrhoidal veins. They are 
frequently a source of hemorrhage which in turn may be the real cause 
of an obscure ancemia, often of a most severe type. Furthermore the 
frequency of the lesion may lead to the too ready acceptance of a patient's 
diagnosis and a failure to recognize the existence of rectal fissure, foreign 
body, malignant growth, tuberculous or syphilitic ulceration or fistula. 
A rectal examination is too often neglected though its disagreeable 
features are in part removed by the use of the rubber glove or finger 
shield. Hemorrhoids are easily recognized if superficial, the patient 
being asked to strain and bear down, when the reddish blue nodules 
will become evident. Skin tags and condylomata are common but 
easily differentiated. Internal hemorrhoids may require the use of 
the speculum, though usually recognized by digital examination. Re- 
tained fecal matter has a characteristic feel and malignant growths 
are peculiarly indurated and firm. In any rectal examination the 
tonus, i.e. resistance offered by, and grasp of the anal sphincter should 



* Test. Powder the stone or gravel, add 20 c.c. of ether, mix thoroughly, 
filter, and evaporate filtrate, divide residue in 3 portions. No. 1 is dis- 
solved in hot alcohol, allowed to evaporate without heat and the residue 
examined for the rhomboid crystals of cholesterin. No. 2 is treated with 
HC1 and a trace of ferric chloride; a blue color on evaporation indicates 
cholesterin. No. 3 is placed on a slide, treated with a drop of concentrated 
sulphuric acid and covered. The cholesterin crystals show carmine margins. 
Another portion may be treated with dilute HC1, heated, cooled and 
treated with chloroform; to the chloroform extract Gmelin's test for bile 
pigment is applied. 



DISEASES OF THE INTESTINES — ENTERITIS. 279 



be noted. It is markedly relaxed in certain organic nervous diseases 
and in obstruction of the rectum and sigmoid flexure. 

ENTERITIS. — In the diarrhceal diseases one must distinguish those 
affecting the small intestine alone from those involving the colon exclu- Enteritis 
sively or in part. The latter, more severe and likely to be attended by Colitis. 
serious complications, are described under dysentery and entero-colitis 
nearly all forms of enteritis are trivial and temporary in the case of 
the adult but may assume considerable importance in the case of infants 
and young children, occurring usually under conditions of improper 
sanitation or still more frequently in artificially or badly fed infants. 
Bowel disturbances in breast fed infants are rare and usually temporary 
and trivial unless secondary to some grave primary condition. All 
varieties are prone to appear during hot weather, particularly when 
extreme variations in temperature and humidity are present, and reach 
their maximum in prevalence and mortality in July and August. Milk 
and water are probably the chief vehicles of contagion but the demon- 
stration of a specific bacillus for the ordinary diarrhceal diseases must 
await further investigation inasmuch as a large variety of organisms are 
found, many of which are quite competent in themselves to produce de- 
cided symptoms or to act with and intensify the virulence of others.* 

Clinical Varieties. — We recognize (i). Acute Intestinal Indi- 
gestion. (2). Acute Fermentative Diarrhoea. (3). Cholera 
Infantum. 

Morbid Anatomy. — The pathologic changes in enteritis vary from 
a mere congestion or catarrhal inflammation of the mucosa with slight Variable 
infiltration of the submucosa and enlargement of the lymph follicles, 
to actual ulceration. Ulcerated areas are ordinarily limited, originat- 
ing at the follicle but extending by the coalescence of contiguous ulcers. 
In combined lesions of the upper and lower bowel one may of course 
have all the changes described under dysentery. In the more severe 
types, particularly the combined form, broncho-pneumonia is common 
and the viscera present evidence of severe toxaemia. 

Acute Intestinal Indigestion. — Colicky pain, tympanites, and 
diarrhoea may come on suddenly, immediately or from several Acommon 
hours to a day after some dietetic indiscretion or, without apparent 
cause;f the fever is usually moderate and of brief duration, the pulse 

♦Much interest attaches to a bacillus recently discovered by Duval and 
Bassett which closely resembles Shiga's bacillus of dysentery and has been 
found in a large number of eases of the Summer diarrhoeas of children. 

t These attacks are frequently of gastric origin. 



severity, 



ailnit 



. 



28o 



MEDICAL DIAGNOSIS. 



Stools. 



Severer 
type. 



Stools 



Reflects 
primary 
disease. 



High 
mortality. 



Violent 

choleraic 

symptoms. 



rate is increased and in the child may be extremely rapid. The stools 
are at first fecal, then water) 7 and contain mucus and food particles 
imperfectly digested; such an attack is ordinarily cut short by the 
administration of some appropriate cathartic, such as castor oil. 

Acute Fermentative Diarrhoea. — This is characterized by more 
marked symptoms throughout and may come on suddenly or succeed a 
milder attack of acute intestinal indigestion. Vomiting is usually 
present, the fever may reach 105 F., the pulse is rapid, nervous symp- 
toms are pronounced, exhaustion marked and, in children, convulsions 
are not uncommon at the onset. The stools are more frequent than in 
the simple form, rapidly become watery, are green in color and contain 
much mucus. The disease is ordinarily of brief duration and favor- 
able termination, but may prove the commencement of an ileo colitis 
and may terminate fatally by coma, exhaustion or broncho-pneumonia. 

Chronic Enteritis. — Hardly justifies a separate description, being 
characterized by intermittent or persistent symptoms of a mild sort 
which mirror the acute attacks. If long continued it impairs strength 
and nutrition and it may be associated with mild daily diarrhoea, mere 
unformed stools, or, obstinate or alternating constipation. 

CHOLERA INFANTUM.— This ailment, remarkably fatal and 
prevalent in the large cities amongst the poor, may affect the children 
of any age and is both sporadic and endemic. The onset is usually 
sudden, with high temperature.* Vomiting is usually present, and the 
stools at first fetid may reach 20 or more daily and rapidly become 
watery, light yellow or greenish, then colorless and odorless. There is 
marked thirst, the urine is scant and often albuminous and the disease 
usually terminates fatally, often with delirium, stupor or coma and per- 
haps convulsions. Marked tympanites is not present nor is the abdo- 
men tender but there is evidence of profound collapse, the features 
being pinched, the skin ashy gray and the surface usually cold even 
though rectal temperature may be high. Ileo-colitis is predominatingly 
a dysentery and will be described under that heading; the small intes- 
tines seem to be primarily involved, but symptoms very soon become 
distinctly dysenteric. 

DYSENTERY.— Definition.— A term applied to a group of dis- 
eases characterized by acute or chronic inflammation and ulceration of 
the lower bowel, diarrhceal stools, containing blood and mucus, and , 
associated with colicky pain and tenesmus. 

* This must be taken by rectiim or vagina because of low surface tem- 
perature. 



^ 



DISEASES OF THE INTESTINES — DYSENTERY. 



28l 




Fig. 120. 
Amoeba Coli. 
(After Braun.) 



Etiology. — The disease may be primary or secondary, acute or 
chronic. The secondary cases depend upon a primary cause, such as 
tuberculosis, syphilis or Bright's disease. The primary cases fall under 
three heads: — (1). Amoebic dysentery. (2). Acute specific dysentery 
(tropical dysentery). (3). Acute catarrhal dysentery (acute ileo -colitis). 

Amoebic Dysentery. — The amoeba dysenteriae was first described 
by Lambl and Losch in 1859 an d first identified in hepatic abscess by 
Kartulis, but to Osier's description (1890) and 
careful work we owe most of our knowledge of its 
importance as an etiologic factor. It is from 15 to 
20 fi in diameter, i.e. about twice the diameter of 
the red blood cell, contains a nucleus and one or 
two vacuoles surrounded by an inner granular zone 
and a clear outer zone. It causes from \-\ of all 
cases of tropical dysentery and if a warm slide is 
used for examination the amcebae may be readily 
identified by their structure and movement and are 
usually contained in the flakes of mucus or pus of the fecal discharges 
or may be obtained from abscesses or stained in situ in tissues. 

Acute Specific Dysentery (acute tropical dysentery). — Practically 
all tropical dysenteries not due to the amoeba are caused by Shiga's 
bacillus which produces the disease in animals by inoculation and is 
agglutinated by the blood serum of affected patients. 

Acute Catarrhal Dysentery (acute ileo-colitis), (follicular dys- 
entery). — This is the ordinary well known form of dysentery encoun- 
tered in the temperate zone. No specific germs have been isolated but 
a large variety have been described as associated with the process. 

Diphtheritic Dysentery. — This is characterized by diphtheritic 
inflammation with extensive infiltration and formation of sloughs. It 
is often secondary to exhausting chronic diseases such as chronic neph- 
ritis, heart disease and malaria. 

Symptomatology. — This is essentially the same for all varieties 
though varying greatly in degree. Any form may become chronic, 
tropical forms are both endemic and epidemic, and for their develop- 
ment all forms of primary dysentery elect hot weather. It will bo 
noted that the symptoms are precisely those that might be expected 10 
follow inflammation of the lower bowel plus widely varying degrees 
ot" toxaemia. The onset is sudden and violent in all tropical forms, 
being often associated with chill, whereas the milder variety is often 
preceded by an initial diarrhoea. Abdominal distress and fever are 



Osier's 
work. 



Amoebae 

readily 

recognized 



General 

t> pe. 



Violent 

onset. 



w 



282 



MEDICAL DIAGNOSIS. 



Emaciation 
and ex- 
haustion. 



Often 
malarial. 



Usually 

easy. 



likely to be high during the active stage of all forms and febrile phenom- 
ena are marked. Essential symptoms. Purging, marked tenesmus, 
severe colicky pains, constant desire to go to stool, excessive thirst, great 
prostration, and, tenderness of varying degree over the descending colon 
are symptoms common to all forms. The stools. These contain mu- 
cus, blood and scybala, and in the severer forms pus and sloughs. 
The number of stools varies greatly, but may reach 100 or more in 
the 24 hours. They tend to become fetid and sanious in severe and 
unrelieved cases. The exhaustion is great yet vomiting and gastric 
irritation are often absent. Emaciation is of course rapid and in 
severe cases extreme. Ileo -colitis is usually preceded by a short period 
of ordinary diarrhceal stools and it must be remembered that in chil- 
dren mucus and blood may appear in any severe diarrhoea. 

Chronic Dysentery. — Chronic indigestion, recurrent dysenteric 
attacks of varying degrees of severity and marked emaciation are the 
chief features in chronic cases. Many of these have been found to 
be due to the persistence of a malaria in soldiers returning from the 
tropics, but any form may become chronic and the irritability of the 
lower intestinal tract may last for a few weeks or months or even for 
many years. 

Differential Diagnosis. — The peculiar character of the diarrhoea 
with its bloody stools and marked tenesmus serves to distinguish the 
acute form; amoebae should be searched for in suspicious tropical 
dysentery and the specific agglutination reaction sought. Typhoid fever is 
readily differentiated by its gradual onset, diazo-reaction, rose spots, 
temperature curve and finally and conclusively by the agglutination 
test with the typhoid germ. As it ordinarily wholly lacks the charac- 
teristic dysenteric phenomena confusion can seldom arise. Tuberculous 
or malignant ulcers and foreign bodies in the rectum may cause attacks 
more or less closely simulating chronic dysentery, but the associated 
lesion and the results of local and microscopic examination will ordi- 
narily distinguish them. 

Mortality and General Comment. — The death rate is of course 
highest in the severe tropical forms and dysentery of the temperate zone 
is seldom fatal except in children and old people, or, persons exhausted 
by disease. On the other hand the total mortality in chronic dysentery 
under conditions of poor food, overcrowding and general insanitation 
may be very heavy. The United States government is still paying a 
large number of persons for disability attributed to chronic dysentery 
of the Civil war and the deaths during that four-year period reached 



DISEASES OF THE INTESTINES — NEUROSES. 



283 



Neuras- 
thenic 
women 
chiefly. 



an enormous total. The mortality in Japan for the decade following 
the first introduction of the disease reached 247,000. 

Membranous Enteritis (membranous diarrhoea, mucous colic). — 
Definition. — An affection characterized by the presence of mucus, 
in quantity, in the feces. Etiology. — More common in women than in 
men, this affection seems largely dependent upon the element of hysteria 
and neurasthenia, but is a relatively rare disease, most frequent in 
connection with an enteroptosis or achylia gastrica though met with 
independently of those affections. Symptoms. — Following an attack 
of obstinate constipation, violent, colicky pains occur associated often- 
times with diarrhoea, perhaps of a dysenteric type, and more or less 
decided dyspeptic symptoms. Mucous masses are discharged which Mucus 
are usually grayish white, ribbon like or membranous, rarely, forming 
complete molds of the intestinal canal (tubular form). Their nature 
may be proven by Pariser's method.* 

MISCELLANEOUS INTESTINAL NEUROSES. — Rectal 
spasm is almost invariably secondary to inflammatory or ulcerative proc- 
esses either of the rectum itself, the colon, the anus or neighboring 
organs, rarely it is supposed to be primary. Defecation is intensely 
painful, the anus is sensitive and resistant, an anaesthetic being required 
for an examination. Peristaltic unrest associated with borborygmi 
may be primary or secondary. The former is a pure neurosis, the 
latter may be associated with various gastric disturbances or with 
actual obstruction. The condition is usually accompanied by con- 
stipation and in its primary and severe form by hysteria, neu- 
rasthenia or hypochondria. It is as a rule trivial and unimportant. 
Meteorism. — Gaseous distension is a mere symptom too well known 
to require extensive description and results chiefly from the fermen- 
tation of carbohydrates or proteids, frequently associated with an 
obstruction, usually temporary and purely neurotic, but is also an impor- 
tant manifestation in true obstruction and peritonitis. It may prove a 
troublesome and dangerous condition in the typhoid state or any virulent 
infection and is particularly dangerous in pneumonia and chronic 
incompensated disease of the heart. Enteralgia lias more basis in 
fact than gastralgia being descriptive of ordinary colicky pain of intes- 
tinal origin whether it be primary or secondary. 

Hypogastric Neuralgia. — This term has been applied to a painful 
condition localized in the epigastrium and Lower part oi the back and 

* They air treated with sublimate alcohol and then yield a green color 
with Ehrlich's triacid stain in contradistinction to fibrin which stains red. 



Sometimes 

serious. 



284 



MEDICAL DIAGNOSIS. 



Often 
obscure. 



Gradual 
onset. 



Regional 
variations. 



associated with sense of pressure in the rectum, bladder, uterus and 
vagina. It is purely a symptom, undoubtedly dependent upon uterine, 
ovarian, hemorrhoidal and other similar conditions. Hyperesthesia, 
Paraesthesia, Anaesthesia. — The intestines share with other portions 
of the body these symptoms of hysteria or neurasthenia and they not 
infrequently take the form of aura in epilepsy. They are important 
only to the possessor of them save in actual disease of the brain and 
cord when rectal anaesthesia may be associated with sphincter paralysis, 
or, in the cases where the anaesthesia leads to a serious accumulation of 
fecal masses. Intestinal neurasthenia is given a place by most 
authors but it is doubtful whether the condition should be so 
dignified. The term really applies to the neurasthenic state with 
predominance of abdominal symptoms. Paralysis of the Intes- 
tines. — This has already been referred to on page 65. The con- 
dition may be a very serious one and presents many of the symp- 
toms of obstruction. It is associated with direct abdominal injury, 
laparotomy, chronic inflammation and ulcerative diseases of the 
intestinal tract, with profound hysteria, melancholia, hypochon- 
dria or actual organic disease of the brain and cord and is frequently 
observed in prolonged and massive fecal impaction. 

CHRONIC INTESTINAL OBSTRUCTION.— Acute obstruction 
has been dealt with on page 64. Chronic obstruction may be due 
to the same factors and one is chiefly concerned with its recogni- 
tion. 

Symptoms. — These are extremely variable and often obscure. The 
history of previous ailments is important as is the history of constipation, 
diarrhoea or symptoms suggesting possible ulceration or appendicitis. 
Little stress should be laid upon the pipe-stem or tape like conformation 
of the stools as these may be met with in spastic constipation or anal 
spasm. The gradual onset of the symptoms is characteristic. At 
first hardly noticeable, they may become severe and troublesome and 
always depend greatly upon the site of the obstruction. Duodenal 
stenosis produces symptoms strongly resembling pyloric obstruction 
and is frequently associated with the vomiting of bile in quantity thus 
indicating a stricture below the papilla of Vater. Any marked obstruc- 
tion in the small intestine will be accompanied by a great increase of 
indoxyl, and the more remote it is from the stomach the more will the 
colicky pains and constipation predominate over the gastric symptoms, 
nausea and vomiting. If in the lower ileum or colon there may be no 
gastric symptoms. Local distension of the abdomen or visible peris- 



DISEASES OF THE INTESTINES — CONSTIPATION. 



285 



talsis may give a clue to the site and gurgling and bubbling sounds 
may be audible and palpable with or without the pressure of the hand. 
It may be possible to recognize the large peristaltic waves of the colon 
as compared with those of the lesser intestinal coils, but it is evident 
that this sign must often fail. 

Chronic intussusception is usually associated with palpable tumor, 
bloody stools and tenesmus as in the acute form, its most frequent 
site being at the ileo-caecal valve. Old appendiceal adhesions may 
produce chronic obstruction in the same region but lack all distinctive 
symptoms of intussusception. In this connection it may be said that 
following appendicitis, adhesions may occur about the caecum or the 
ascending portion of the colon producing obstinate constipation and 
frequent attacks of more or less extreme pain though the appendix is 
found at operation practically normal and free.* 

CONSTIPATION. — This common and often troublesome symptom 
may be caused (a) By the character of the food taken, being more common 
in those taking an exclusive meat diet than in vegetarians, (b). Dis- 
turbances of innervation, more frequently than from any other cause. 
It is seen in hysterical neurasthenia, brain injuries, simple neglect or 
lack of proper habit, injuries and disease processes affecting the peri- 
toneum, lead poisoning, nervous dyspepsia, hyperchlorhydria, etc., etc. 
(c). Mechanical causes, amongst which are weak abdominal musculature, 
strictures, growths and the recumbent posture, (d). Reflex causes 
and direct irritation as in fissure of the anus, hemorrhoids, rectal ulcer, 
prostatitis, and displacement of the uterus or ovaries, (e). Fever 
and other conditions associated with profound toxaemia, diminished 
secretion or excessive abstraction of fluids, (f). Chronic disease of 
the stomach, colon or small intestine. 

Clinical Divisions. — One distinguishes an atonic and a spastic form , the 
former representing either a weak intestinal musculature or impairment 
of its nervous mechanism. This is seen in chronic venous congestion 
(chronic heart disease, hepatic cirrhosis, etc.) or in states of profound 
general debility, neurasthenia, hysteria or certain organic nervous ailments. 

Spastic constipation is characterized by permanent increased 
tonus of the intestines and the rectal segment. The spasm may 
be of variable duration and involve one or many intestinal 
segments in varying degree. If the whole small intestine is affected 
a scaphoid abdomen is produced as is seen in spinal meningitis 

* The author lias had several of these eases operated upon with excellent 
results. 



Tumor and 

bloody 

stools. 



Adhesions 
after ap- 
pendicitis. 



Etiology. 



Atonic. 



286 



MEDICAL DIAGNOSIS. 



Stools. 



Colic. 



Etiology. 



Hospital 
cases. 



Various 
sequela?. 



Readily 
detected. 



Obscut 



Site. 



or in certain irritative cerebral lesions. More frequently the colon 
is involved and yields no symptoms on inspection save that the stools 
resemble round hard balls often like goat droppings or the pipe-stem 
or tape like forms. One somewhat characteristic symptom of spastic 
constipation is intermittent pain in the left lower abdominal segment 
relieved by stool or enema. This at times is very severe and consti- 
tutes a type of colon colic. 

FECAL ACCUMULATION is most common in persons suffering 
from profound toxaemia in the acute infectious diseases such as typhoid, 
in the insane, or, in profoundly hysteric or neurasthenic individuals. 
Careless physicians, house officers or nurses are pretty sure to encounter 
them. They are sometimes associated with profound auto-intoxication, 
partial or complete intestinal paralysis and acute gastric dilatation. 
Such masses frequently produce neuralgic symptoms or even a sciatica 
and, if the condition be of long duration, the utmost difficulty will be 
encountered in attempting to relieve it by enema or by physic. Rectal 
obstruction is easily diagnosed by the finger and speculum. It may 
take the form of irregularity, greatly diminished frequency, or, a mere 
diminution in quantity, the fecal passages being chronically insufficient. 
In fecal impaction and indeed in almost all forms of constipation pal- 
pation of the rectum or even the relaxed abdominal wall is sufficient 
for the detection of fecal masses. If actual obstruction occurs from 
this cause ileus is closely simulated, otherwise the symptoms are too well 
known to require description. 

DUODENAL ULCER.— Reference has been made to this condi- 
tion under gastric ulcer from which it can rarely be distinguished. 
Its etiology is unknown save in the case of extensive superficial burns 
of the skin which frequently produce it. It is less frequent than 
gastric ulcer in the ratio of 1-12 or 15, occurs ordinarily in 
older persons (between 30 and 60) and occasionally affects chil- 
dren, even in infancy. Its most frequent site is the upper ascending 
or horizontal portion of the duodenum, immediately behind the pyloric 
fold. Its relation to the diverticulum of Vater when it occurs in the 
descending duodenum makes it likely to involve the pancreatic and 
biliary ducts. It may be single or multiple and may cause a localized 
peritonitis by perforation. 

Symptoms. — These closely resemble ulcer of the pylorus though the 
gastric symptoms are usually markedly less. Hemorrhage occurs in 25 
or 30%, but blood only occasionally appears in the vomilus. Symptoms 
of perforation have already been described on page 263. Symptoms 



^> 



DISEASES OF THE INTESTINES — TUBERCULOSIS. 



287 



Rare and 
obscure. 



0) icterus occasionally occur and help the diagnosis and the pains do not 
radiate to the back and are usually distinctly right-sided. 

Prognosis. — Complete recovery is rare, relapse is common, perfor- 
ation more frequent than in gastric ulcer. The hemorrhage is often 
severe, occasionally fatal and malignant growths may develop upon the 
ulcer base. 

THROMBOSIS AND EMBOLISM.— This rare condition results 
usually from a clot in the left auricle in cases of mitral disease, 
thrombosis being the common form and the superior mesenteric the 
almost invariable site. The condition can seldom be recognized ante- 
mortem. Septic emboli carried into the smaller branches 0} the intes- 
tinal arteries from an endarteritic or septic focus may cause ulcer and 
produce severe colicky pain, localized tenderness and bloody diarrhoea. 
Embolism of the inferior mesenteric artery is very rare, the symptoms 
not lending themselves to exact diagnosis. 

TUBERCULOSIS OF THE INTESTINES.— This is rarely pri- 1 
mary but a common secondary manifestation, occurring in a large per- 
centage of the advanced pulmonary cases. It affects chiefly the lower 
portion of the ileum and may extend downward even to the rectum or 
to a variable extent upward. The ulcers are irregular in shape with Ulcers. 
unclean bases and bright red margins which are usually undermined or 
overlapping. They readily form adhesions and hence seldom perfor- 
ate. Owing to their tendency to encircle the intestine they may in 
rare instances heal and produce cicatricial stenosis. Diagnosis is evi- 
dent from the pus, blood and tubercle bacilli in the stools, associated 
with localized pain and tenderness, and, usually, a pre-existent known 
tuberculosis. 

SYPHILIS OF THE INTESTINES.— Syphilitic ulcers formed by 
the softening of gummata occur, congenitally, in the small intestines, but in 
the acquired form, chiefly in the colon, rectum and anus. They present a Ulcers 
bacon like appearance with well defined margins and an indurated base. 
Ulcers are occasionally observed in secondary syphilis and a form of 
ulceration of indefinite causation termed "toxic" occurs occasionally in 
connection with the cachexias of leukaemia, scurvy, nephritis and the like. 

Intestinal Parasites. — See page 494. 

ENTEROPTOSIS (Glenard's disease).— This syndrome represents 
a ptosis involving the Stomach, intestines, kidneys, liver and spleen. 
In one type characterized by absence of subjective symptoms, the 
condition is associated with extreme relaxation of the abdominal 
wall, either from repeated pregnancies or recurring ascites, which 



Secondary, 
common. 



Tw typo: 



>> mptom- 
less form. 



r 



288 



MEDICAL DIAGNOSIS. 



Its op- 
posite. 



Objective 

vs. 
Subjective. 



Ptosis. 
Colon. 
Pain. 



Latent 
cases. 



Mortality. 

Age. 
Sex. 



often involves separation of the recti. In the other, the same 
condition in lesser degree is associated with marked neurasthenia 
and the victims are usually young, thin females. Symptoms. — The 
first group is one of outward signs, the second of subjective symp- 
toms, and the absence of complaint in the former is striking in contrast 
: with the apparent disturbance of normal relations, the abdomen 
being relaxed and usually thin, the stomach if inflated being plainly 
visible and greatly displaced, while intestinal peristalsis and to a slight 
degree the gastric waves may be evident. If gastric dilatation be present 
it is likely to be that of atony, the peristalsis lacking the vigor of that 
seen in pyloric stenosis with ectasia. Palpation shows displacement 
of the kidney (see movable kidney, page 365), sometimes a less marked 
displacement of the liver and, occasionally, decided mobility of the spleen. 
The colon is so prolapsed as to form a more or less perfect V and may 
be felt as a cord crossing the abdomen at or below the navel. In the 
second group there are symptoms of nervous dyspepsia, dragging pains 
usually lumbar, but often sacro-iliac, subjective epigastric or umbil- 
ical throbbing and, in short, the combined phenomena of nervous dys- 
pepsia and more or less pronounced neurasthenia. Not only do we 
frequently find the first type of cases lacking in symptoms but even 
those of the second type may develop only after an exhausting illness, 
some profound emotional disturbance, or the disclosure of the diagnosis 
by the physician. 

APPENDICITIS. — The remarkable prevalence of appendicitis as a 
disease is due merely to its substitution under correct pathology for the 
old term peritonitis which formerly covered its secondary and most fatal 
sequence and to a better knowledge of the sources of abdominal pain. 
Nowadays, aside from traumatism and perforating ulcer of the stomach 
and duodenum, acute general peritonitis is rare in the male save as a 
result of appendicitis, while, in the female, appendicitis is overwhelmingly 
predominant though the pelvic structures share the dubious honor 
Prevalence. — Appendicitis causes upwards of 2% of all deaths in the 
United States, a higher mortality than is shown by the statistics of 
foreign countries. Etiology. — The disease is more prevalent in the 
young, being most frequent under the age of 30 and comparatively 
rare as a primary lesion in persons of middle age. It is slightly more 
frequent in the male than in the female and in the latter is frequently 
combined with inflammation of the pelvic viscera* An indiscreet 



* Dr. A. McLaren and other surgeoi 
male predominance a myth. 



of wide experience believe this 



DISEASES OF THE INTESTINES — APPENDICITIS. 



289 



diet no doubt plays a part, particularly in recurrent cases, and occupa- 
tion is a factor, especially that involving hard muscular work or 
severe strains such as lifting. 

Symptoms. — Acute appendicitis yields symptoms varying with 
the nature and extent of the inflammatory process, but all showing 
certain well defined characteristics. The subacute and acute catarrhal 
form in which the local changes are slight may yield no definite 
symptoms or signs, or, disproportionately and misleadingly severe ones. 
The acute diffuse form is associated with an active inflammation 
and infiltration, often with erosions of the mucosa, and produces 
usually but not always marked symptoms. Purulent and gangren- 
ous appendicitis are advanced forms of the same primary lesions. 
Abdominal pain, fever and localized tenderness are the essential features 
of all acute forms. Pain of sudden onset and a tendency to localize 
itself within 48 hours, usually earlier, at a point representing the inter- 
section of the outer edge of the right rectus with a line drawn from the 
anterior superior iliac spine to the umbilicus (McBurney's point) and 
the associated localized tenderness really make the diagnosis. Fever. 
Without fever a positive diagnosis of acute appendicitis is difficult, 
yet cases occur in which local and even general peritonitis are present 
without fever. Vomiting and constipation are usually marked features, 
children may show diarrhoea. Physical Signs. — Early in the disease 
there are none of importance save the evident pain and distress and 
fever. Palpation may show increased resistance (muscular rigidity) 
with or without tenderness in the region of McBurney's point, but in 
many cases this symptom is delayed for 24 hours or more. Doubtful 
early cases justify McMonagle's manoeuvre, i.e. fixation of the knee 
in extension and asking patient to attempt flexion of the thigh on abdo- 
men against resistance, while the unoccupied hand palpates the abdomen. 
Cutaneous hyperesthesia of the nth dorsal nerve may be present. 
The relaxation of muscular rigidity under anaesthesia in perforative 
cases is said to occur last over the exact site of the perforation. Rectal 
or vaginal examination may yield important information in obscure cases 
and should never be omitted. Percussion is of no special value and 
auscultation is negative. As the disease advances exquisite local ten- 
derness develops, there is a tendency for the patient to draw up the 
leg of the affected side, and in certain cases palpation may reveal an 
actual induration, sometimes in the caval region, more often just above 
Poupart's ligament. Bladder irritability is common ami. in the female. 
involvement of the appendages by inflammatory adhesions is frequent. 

19 



Occupa- 
tion. 



Obscure 

cases. 



Frank 
cases. 



Essential 
symptoms. 



McBur- 
ney's point. 



Lacking 

early. 



Important. 



Tender- 



290 



MEDICAL DIAGNOSIS. 



Shock and 
collapse. 



Misleading 
signs. 



Sudden 



Examine 
urine. 



Pelvic 
disease. 



Wide 

variations. 



Bowel 
drainage. 



Recur- 
rence. 



Perforation and General Peritonitis.— Temperature may be low 
I or absent, the pulse slow, the pain may disappear and the patient 
believe himself better, but soon the fades assumes the Hippocratic 
cast, the abdomen is distended, motionless and strikingly resistant. 
Both knees are drawn up, the pulse becomes rapid, wiry, and small, 
the tongue dry. It should never be forgotten that in the earlier stages 
of appendicitis the pain and tenderness may be general, and that in per- 
foration and general peritonitis the patient 7 s sensations and the tempera- 
ture may be most misleading. 

Differential Diagnosis of Acute Appendicitis. — Any attack of 
acute abdominal pain attended by fever should at once suggest appendi- 
citis as the cause, the suddenness of the onset being an important 
though not absolute distinction as regards typhoid, for which it has 
been many times mistaken. Renal colic may prove deceptive in two 
forms, first, the so-called Dietl's crises which usually lack the ultimate 
localization of appendicitis. Secondly, the passage of calculi through 
the ureter and especially such as are temporarily lodged in its lowest 
and narrowest portion. The recognition of renal colic should offer no 
difficulty by reason of the localized original pain over the kidney and 
its distribution. Furthermore, even the ureteral cases are usually made 
clear if the urine be examined as it always should be before any opera- 
tion is undertaken. Several times in the author's experience such 
patients have narrowly escaped the knife. Gall stone colic is usually 
definitely localized both as regards points of tenderness and referred 
pain and pelvic peritonitis presents bilateral rigidity, hypogastric pain 
and localizing symptoms per vaginam. Nevertheless acute tubal or 
ovarian inflammation or a pelvic situation of an inflamed appendix 
may complicate the diagnosis, and a local examination is always neces- 
sary in women. Strangulation and intussusception differ from appendi- 
citis in the fecal vomiting of the former and bloody stools of the latter. 

Prognosis. — Mild catarrhal cases recover without operation after a 
few days' illness, those going on to suppuration may result in a general 
peritonitis, gangrene, or perforation attended with extensive purulent 
inflammation in remote regions, one of which is the perirenal tissue. 
Certain of the acute suppurative cases rupture into the bowel, draining 
the abscess cavity, and may show a remarkable freedom from recur- 
rence. The question of surgical interference in appendicitis is a diffi- 
cult and important one. Surgical consultation should be the invariable 
rule, and surgical judgment should ordinarily be accepted. No matter 
how mild the case, a second attack usually calls for operative interfer- 



DISEASES OF THE INTESTINES— APPENDICITIS. 



291 



Obscure. 



Often 
misnamed. 



I-V 



associa- 
tions. 



ence and in those who live in, or whose duties take them to remote 
regions, a primary or interval operation should be the invariable rule.* 
CHRONIC APPENDICITIS.— As physical signs may be wholly 
lacking and the symptomatology suggestive of disease of other organs, 
the diagnosis usually depends upon a definite history of antecedent acute, 
subacute or recurrent appendicitis, which may masquerade under the title 
of u typhoid fever" "inflammation of the bowels," "gall stones," "renal 
colic," "gastralgia" or "ovarian trouble." Occasionally there are en- 
larged and thickened appendices or old inflammatory masses that may 
be palpated. Quite frequently there are mild but definite localizing 
symptoms and slight fever (99.5 F) at the time of examination. Sug- 
gestive symptoms are: — pain over the stomach, gall-bladder and umbilicus i Symptoms 
increased by appendiceal rather than by local pressure; hyperesthesia s 
over right edge of rectus, dull or colicky pain on exercise and pain asso- 
ciated with visible peristalsis in the ileo-ccecal region (obstructive adhe- 
sions). Right -sided dysmenorrhoza following an acute illness suggesting 
appendicitis, diminished power of endurance and persistent malnutrition 
are frequently present and a dull aching or even colicky, appendiceal 
pain may come on at the height of digestion. It should be borne in Misleading 
mind that chronic appendicitis is frequently associated with movable 
kidney, chronic indigestion, obstinate constipation, alternating diarrhoea 
and constipation and mucous (membranous) colitis. Further, that 
symptoms of obstruction may be caused by an old appendicitis with 
dense adhesions. A somewhat extended observation has convinced ' 
the author that no surgeon or internalist can hope to recognize all of 
these cases without an exploratory operation. 

Differential Diagnosis of Chronic Appendicitis. — This must 
depend upon the factors already given. In most instances the past 
history and the acute or subacute attacks are the determining factors. 

ACUTE INTESTINAL OBSTRUCTION (see pain-abdominal, 
p. 64). 

ACUTE PERITONITIS.— This may be local, diffuse or general and 
its causes are too numerous for detailed description, but resolve the 
cases into primary and secondary groups. The so-called primary or 
idiopathic peritonitis is a dubious clinical entity. Secondary peritonitis 
means an extension of inflammation from any structure to the adjacent 
peritoneum. Thus it may arise from traumatism including operation, 
from extension, in the severer inflammation of the intestinal tract, 

* In children primary operation is usually indicated if the diagnosis can 
be made within the first 34 hours. 



Primary 

rare. 



292 



MEDICAL DIAGNOSIS. 



Misleading 
forms. 



from perforation due to absc ss or ulcer, and from chronic ailments 
Etiology. such as cancer and tuberculosis. Furthermore, the lowering of vitality 
in certain chronic diseases seems to render the peritoneum less resistant 
to the action of germs. The evidences of infection of the peritoneum 
are extremely varied, certain cases associated with profound collapse 
and death subsequent to abdominal operation showing no lesion save 
perhaps points of congestion. In some there is little fluid or fibrinous 
exudate, in others a large amount of fluid and exuded lymph, the fluid 
being sero-fibrinous, purulent, putrid, or, in wound infection carcinoma 
and some tuberculous cases, hemorrhagic. Symptoms. — In general 
peritonitis of the perforative or septic type, the fades assumes the 
Hippocratic type, there is usually severe initial pain and evidence of 
marked prostration or collapse, fever may be preceded by chills and rise 
rapidly to a high point or chill and fever and pain be absent. Con- 
tinuous high fever is seldom seen. Painful vomiting and frequent mic- 
turition are common. The urine is scant, indicanuria is marked, the 
pulse is small and tense, and the position is rigidly dorsal, with the knees 
drawn up and the abdomen tense, usually distended but occasionally 
flat, the vomitus is yellow and bile stained or later pure green or even 
brownish black and of fecal odor. Wasting is rapid, distension tends to 
increase, tympany being marked, and there is general tenderness of an 
extreme degree. It should be emphatically stated that obliteration of 
splenic and hepatic dulness is not confined to perforative peritonitis 
, but may occur in any extreme case of tympanites. Dulness in the 
flanks is usual, indicating fluid, and the difficulties of diagnosis in these 
cases are chiefly related to the identification of the primary lesion. 
"Hysterical peritonitis" may however produce a typical clinical picture 
on inspection, but fever, wiry pulse and indican increase are usually 
absent. Obstruction of the bowel offers great difficulty at times and 
demands a careful consideration of the factors stated on page 64. 
Ruptured tubal pregnancy, acute hemorrhagic pancreatitis and various 
other lesions may demand the surgeon's knife for differentiation. 

LOCALIZED PERITONITIS.— In the male the most frequent 
cause of localized peritonitis is appendicitis, in the female tubal 
or ovarian inflammation. A great number of localized inflamma- 
tory conditions of the viscera give rise to limited areas of per- 
itonitis, the degree of inflammatory change and its nature depend- 
ing upon the primary cause. An extended discussion of these 
forms is out of the question. The lesser peritoneum, however, 
must receive special attention because of its frequent involve- 



Usual 
type. 



Urine. 

Attitude. 



Vomitus. 

Wasting 
and ten- 
derness. 



Fluid. 



Various 

confusing 

conditions. 



Appendi- 
ceal or 
pelvic. 



Other 
causes. 



DISEASES OF THE INTESTINES — PERITONITIS. 



293 



ment, its importance and the obscurity of its symptoms. The lesser 
cavity is bounded in front by the gastro-hepatic omentum, the anterior 
layer of the great omentum and the stomach; below, by the upper 
layer of the transverse meso-colon, and extends from the splenic to the 
hepatic flexure of the colon and from the hilus of the spleen to the for- 
amen of Winslow. Above lies the transverse hepatic fissure and that 
portion of the diaphragm covered by the lower layer of the right hepatic 
lateral ligament. In the presence of inflammation its communicating 
opening leading to the greater cavity (foramen of Winslow) may be shut 
off so that inflammatory exudate may cause a tumor in the upper abdom- ! 
inal quadrant. This is markedly affected by inflation of the stomach 
which tends to obscure or obliterate the dull note or even the palpation 
outline of the tumor, and an inflated colon does not cross it, but lies 
below it. This is properly known as "subphrenic abscess," its most 
frequent cause being perforating gastric ulcer. Duodenal ulcer and 
appendiceal abscess account for nearly all of the remainder. Dif- 
ferential Diagnosis. — The symptoms are usually abrupt and associated 
with pain, vomiting, dyspnoea and signs of sepsis. The tumor may be 
palpable in some portions of the upper quadrants, cyst-like in feel, 
markedly obscured by stomach inflation, and not crossed by an inflated 
colon, and when the accumulation is immediately beneath the dia- 
phragm the symptoms strikingly resemble empyema and the abscess 
may rupture through the lung, the pus appearing in quantity in the 
sputum. (See also hepatic abscess.) The author believes that such 
cases may in many instances be differentiated by the absence of respi- 
ratory lateral displacement of the heart (see page 134). // air be pres- 
ent, pneumothorax is simulated, but should be easily distinguished upon 
X-Ray examination by the high position of the diaphragm and under- 
lying shadow. The mortality in this condition is enormous (80%+). 
CHRONIC PERITONITIS.— The plastic lymph associated with all 
peritoneal inflammations, acute or chronic, tends to form adhesion bands 
of greater or less extent, density and permanence, and movable viscera 
often drag agglutinated surfaces apart to form false bands. It should 
also be remembered that in any condition simulating local peritonitis 
the abdominal wall lacks the persistent general or localized rigidity of 
the true ailment. In both acute and chronic forms moreover the ease 
with which the inflammation may spread from peritoneum to pleura 
and vice versa must be taken into account. As Edmund Owen says, 
"the peritoneum acts in inflammation much like an inflamed 
joint," i.e., it seeks functional rest and is exquisitely tender, :. 



Boundaries 

of lesser 
cavity. 



Effect of 
adhesion. 



Stomach 
inflation. 



Offers 
great diffi- 
culties. 



Adhesions. 



Valuable 

point. 



Spreading 

inflamma- 
tion. 



294 



MEDICAL DIAGNOSIS. 



Tender- 
ness. 



Friction. 



Misleading 
signs. 



Transverse 
tumor. 



Seek a 

primary 

focus. 



Obscure 
cases. 



Usual type. 

Pigmen- 
tation. 



arises the characteristic rigidity, constipation and localized tenderness 
and the jact that pressure which relieves ordinary colic is intolerable 
in peritonitis. Further, as in pleurisy, auscultation may reveal areas 
of friction particularly in the region of the subdiaphragmatic organs 
which move in inspiration (chiefly the liver and spleen). Chronic 
adhesions in the form of false bands may cause intestinal obstruction 
but in the ordinary form they may be symptomless or give rise to mis- 
leading and troublesome symptoms, as in two cases recently observed 
by the author in which a chronic appendicitis with acute exacerbation 
was exactly simulated by an extensive adhesion in its neighborhood, 
the appendix being normal. 

PROLIFERATIVE PERITONITIS.— This is characterized by 
marked thickening without extensive adhesions and is usually associ- 
ated with hepatic cirrhosis, more rarely with chronic passive congestion, 
tumors and similar conditions. The effusion is usually small, the vis- 
cera may be included in the thickened layers and the peritoneum may 
be divided into several chambers. Shrinkage of organs may be pro- 
duced and the rolled omentum usually forms a transverse tumor at 
the lower border of the stomach. Nodular growths simulating tubercles 
or malignant nodules may be present. 

TUBERCULOUS PERITONITIS.— This condition varies exactly 
as do pulmonary lesions, there being an acute miliary, chronic ulcerative 
and chronic fibroid form. It may be primary or secondary being fre- 
quently associated with intestinal tuberculosis or disease of the Fallop- 
ian tubes (30-50% of adults). The prostate or seminal vesicles may be 
primarily involved. The incidence as regards sex is as two to one in 
the male as compared with the female. As regards age it is most frequent 
in the 3rd, 4th and 5th decade. As regards race, more common in the 
colored than in the white. Traumatism, cirrhosis of the liver and 
hernia are associated conditions in many cases. Symptoms. — As with 
tuberculosis elsewhere the disease may be symptomless and is usu- 
ally less pronounced than other forms of peritonitis; more rarely the 
onset and course are extraordinarily severe. In general, there is tenderness, 
localized or diffuse, and a temperature sometimes continuous, more often 
hectic in type, usually of slight range, and, a moderate, often hemorrhagic 
ascites. Deep pigmentation of the skin is sometimes observed and 
tumors are encountered due to inclusion and contraction of intestinal 
coils, encysted exudate and adherent omentum, or, in children, to enlarged 
mesenteric glands. 

Differential Diagnosis. — Cases with acute onset and violent symp- 



DISEASES OF THE PANCREAS— PANCREATITIS. 



295 



toms maybe unrecognizable as tuberculous; those with continued fever 
are differentiated from typhoid by the absence of the Widal reaction and 
the continued development and predominance of peritoneal symptoms. 
Omental tumors are usually transverse and somewhat characteristic in 
the shape and feel. The presence of an exudate greatly assists diagnosis. 
In most instances a suggestive family and personal history or the existence 
of tuberculous pulmonary, intestinal or tubal symptoms assist differ- 
entiation. 

CANCER OF THE PERITONEUM.— Secondary cases need no 
special description, they take the form of growths, generally distributed 
and varying from the miliary nodule to large umbilicated growths. 
The omentum is frequently involved and forms a peculiar tumor as 
in tuberculosis. Primary disease is extremely rare and most often 
endothelioma. 

Diagnosis. — A positive diagnosis is easy in secondary cases if the 
primary source be manifest, but is always difficult in the rarer primary 
forms, indeed a positive differentiation is hardly possible without explor- 
ation, the symptoms being almost identical with those of tubercu- 
losis or echinococcus infection in most instances. 

DISEASES OF THE PANCREAS. 

ACUTE HEMORRHAGIC PANCREATITIS.- Etiology. —In- 
fection through the gall-bladder and ducts is the chief source of this dis- 
ease, though bile itself, if forced back into the pancreas by obstruc- 
tion to its normal outflow may produce fat necroses and hemor- 
rhage. It may also be involved in septicaemia, by traumatism, or sec- 
ondarily, in the extension of inflammatory processes from neighboring 
organs. 

Symptoms. — These closely simulate perforation particularly that of 
duodenal or gastric ulcer, the onset being sudden with violent colicky 
pain in the epigastrium, associated with vomiting and collapse, with 
subsequent epigastric swelling. It is evident that a positive diagnosis 
is often impossible. The maximum of tenderness may clearly follow 
the outline of the pancreas and there may be a suggestive history of 
antecedent disease of the gall-bladder. Diagnosis. — The diagnosis 
must be based upon the sudden onset with pain and vomiting, symptoms 
of collapse and the appearance of a fixed tumor corresponding to the 
position of the affected organ. The diagnosis is usually though not 
always made by exploratory section. The urine may show leucin and 



Varied 

types. 



Tumor a: 
exudate. 



Often 
impossible. 



Violent 

onset. 



Surgical 
diagnosis 
usuall) • 



296 



MEDICAL DIAGNOSIS. 



tyrosin after treatment with basic lead acetate, nitration, treatment of 
the nitrate with hydrogen sulphide and evaporation. Prognosis. — 
Recovery is the exception. 

ACUTE SUPPURATIVE PANCREATITIS (pancreatic ab- 
scess). — Suppurative pancreatitis is associated with preliminary di- 
gestive disturbance, fever, possibly of a septic type and what is more 
important by a fixed epigastric tumor. 

GANGRENOUS PANCREATITIS may result from hemorrhage 
or rarely suppurative inflammation. It has no distinguishing symp- 
tom aside from those of the primary hemorrhagic or septic pancrea- 
titis, followed by collapse and death in a few weeks or days. The dis- 
tinction is made post mortem. 

CHRONIC PANCREATITIS closely resembles histologically in its 
two forms, atrophic and hypertrophic cirrhosis of the liver, the former 
condition is frequently associated with diabetes. 

PANCREATIC CYSTS.— The chief characteristics are recurrent 
colic associated with nausea, vomiting and progressive abdominal dis- 
tension, glycosuria, emaciation and a fixed median tumor, cystic in 
feel, and lying above the inflated colon and below the stomach. They 
may attain great size. 

CARCINOMA OF THE PANCREAS.— Primary carcinoma in- 
volves usually the head of the gland. Metastasis or direct invasion of 
other organs is frequent; the condition is rare. Symptoms. — These 
are chiefly those of progressive emaciation, ancemia, intractable dyspep- 
sia, and dull or severe epigastric pain, the stools are often light and 
pasty, muscle fibres of ingested meat may result from faulty pancreatic 
secretion and jaundice and ascites are not infrequent. The tumor is 
median unless the tail of the pancreas be the part involved and gly- 
cosuria, jaundice and various pressure symptoms may be present 

PANCREATIC CALCULI.— The rough round or spiculate stones 
are, in rare instances, associated with violent epigastric colic and may 
be found in the stools. Ordinarily they produce an interstitial pan- 
creatitis or lead to abscess. 

DISEASES OF THE LIVER AND THE BILIARY PASSAGES. 

CONGENITAL ANOMALIES.— An extraordinary variety may be 
found including abnormalities in the size, number and position of the 
lobes, the presence of accessory masses of tissue, complete absence of 
the organ, abnormal mobility, and even its displacement to the left 



DISEASES OF THE LIVER — PYEMIC ABSCESSES. 



297 



side, as is seen in complete situs inversus. It has been found within 
the thorax in cases of diaphragmatic hernia, or following injury, and 
may be markedly displaced downward, or grooved, swollen, and 
thickened by tight lacing. Multiple depressions of a similar sort may 
appear upon its superior surface, and are not satisfactorily explained. 
The gall-bladder may be entirely lacking and curious variations occur 
in the size, number and distribution of its ducts. 

INFLAMMATION OF THE LIVER (acute hepatitis .—Eti- 
ology. — Inflammation may result directly from injury or follow an 
infection, diseases of the stomach and intestines or portal veins, and 
may be either simple or suppurative in character. 

PYEMIC ABSCESS OF THE LIVER.— It will be readily under- 
stood that pyemic abscess, whether single or, as is usual, multiple, may 
result from infection conveyed, directly or indirectly, through arterial, 
venous, or lymphatic channels. Any form of pyemia or general septic 
absorption may result in infective embolism of the hepatic artery, 
a great many of the suppurative and ulcerative lesions of the abdom- 
inal tract result in portal embolism and almost any of the acute infec- 
tious diseases in their severer forms may produce hepatic abscess. 
Amongst the vast number of associated conditions may be mentioned 
ulcer and cancer of the stomach and duodenum, inflammation and 
malignant growths involving the pancreas, gall-bladder or its ducts, and, 
any ulcerative and suppurative process in and about the intestines, 
such as typhoid fever, dysentery, appendicitis, cystitis, prostatitis, 
tuberculosis, etc. Caries of the spine and abscess in and about the 
kidneys may also cause hepatic abscess, as may the echinccoccus, the 
Balantidium coli, ascarides and liver flukes. The so-called tropical 
abscess is almost invariably associated with amoebic dysentery and 
such an abscess is ordinarily solitary (75%). 

Symptoms. — These, usually pronounced and localizing, more rarely 
latent and obscure, are chiefly: — enlargement of the hepatic area or 
localized swelling, pain, and the well known symptoms of sepsis. The 
pain is not usually severe until the abscess approaches the surface and 
is not distinctly localized, but felt both over the liver and in the region 
of the right shoulder blade and in some instances, chiefly at a point to 
the left of the median line, below the costal margin. Enlargement oj 
the liver is an invariable symptom and is usually marked; hence both 
the upper and lower hepatic borders, should be examined and the con- 
dition of the lower interspaces investigated. .1 localized swelling cor- 
responds to the "pointing" of the abscess, is invariably accompanied 



Corset 
liver. 



Usually 
secondary. 



Associated 
conditions. 



Tropical 
abscess. 



Usually 

pro- 
nounced. 



Pain 
variable. 



Localising 

sik'ns. 



, 



298 



MEDICAL DIAGNOSIS. 



Edema. 



Adhesions. 



Sepsis. 



A variable 
sign. 



Sequelae of 
perfora- 
tion. 



Pulmonary 
form. 



Error 
frequent. 



by edema of the superficial tissues, and in some instances may show 
fluctuation. Auscultation may reveal peritoneal friction, due to capsular 
involvement and precisely similar to pleuritic friction, the tendency 
being to form adhesions and limit movement. As might be inferred 
loss of strength and weight is marked, and loss of appetite, morning 
vomiting, and in general, pronounced dyspeptic phenomena. Fever is 
either definitely intermittent or decidedly irregular, and is usually asso- 
ciated with chills, and severe nocturnal sweats. Jaundice may or may 
not be present and no stress should be laid upon its absence. It is 
said that the decubitus of such a patient is characteristic, the right 
knee being drawn up, the right shoulder lowered, but this might apply 
to any disease affecting this particular region. Complications. — The 
only complication needing attention is perforation. A knowledge of the 
anatomical structure enables one to understand in how many directions 
and with what serious results, an hepatic abscess may burrow and dis- 
charge its contents. Such perforation may occur outward through 
the skin, after the formation of adhesions, either directly or, more fre- 
quently, through a sinuous burrow. It may perforate into the pleura 
and cause empyema, and indeed may cause purulent pleurisy with 
direct perforation and abscess of the left lobe, or, perforate the peri- 
cardium, while perforation into the peritoneal cavity is very rare, as is 
that involving the portal vein, the inferior vena cava and the right kidney. 
Most practitioners have met with cases of direct perforation with 
intervening empyema through the lungs and bronchi. The discharge 
of pus by the bronchus is usually preceded by severe cough, and the 
expectoration of bright red sputum and local examination will indicate 
merely a limited area of pneumonic infiltration. Sometimes it may be 
that the findings are quite negative, yet, shortly after, the patient will 
in a violent fit of coughing, raise a considerable quantity, oftentimes a 
large amount, of pus, intermixed with blood, often brown sero-purulent 
or, bile stained, not infrequently containing shreds of lung tissue. Strange 
to say these cases may go on for long periods with a daily expulsion of 
quantities of pus, in one case reported over a pint, and yet sponta- 
neously subside, leaving only a certain amount of lower chest deformity 
and crippled lung base; the aid of modern surgery is however always 
needed. 

Differential Diagnosis. — Too often these cases are misconstrued 
or entirely overlooked. Stress should be laid upon the existence of 
causative factors. Furthermore, enlargement of the hepatic area is 
invariable. Jaundice when present is extremely suggestive, and local- 



DISEASES OF THE LIVER — TUMORS. 



2 99 



ized swelling, whether over the free surface of the liver or the lower 
right interspace is most important. A distinctly septic trend of the 
symptoms at once suggests abscess. The spleen is enlarged and there is 
marked leucocytosis which may exceed 50,000. In empyema, there is 
usually an antecedent history suggesting that condition and the 
author's sign of unilateral pleuritic exudate (see page 134) should 
prove helpful, as should the character of the pus withdrawn by aspira- 
tion. As between hepatic and subdiaphragmatic abscesses, a surgical 
exploration is often required for positive differentiation. 

Prognosis. — The prognosis depends upon three factors, i.e. the num- 
ber of abscesses, and, the promptness of diagnosis and surgical relief. 
Cases of multiple abscesses are practically hopeless. 

HEPATIC HYPEREMIA— Transient active hyperemias are un- 
important and we have to do essentially with chronic hypercemia, which 
is invariably due to some cause tending to prevent the free flow of blood 
from the liver into the vena cava. Amongst the latter causes may be 
mentioned chronic heart disease, especially such as results in dilatation 
of the right heart, asthma, emphysema, bronchiectasis, pulmonary 
fibrosis and portal thrombosis. Such a congestion, typically shown in 
cases where the tricuspid valve has given way, results in the production 
of the so-called nutmeg liver, Jiere being central lobular congestion 
with peripheral anaemia associated with fatty degeneration. The 
liver is large, though in the presence of long continued congestion it 
may undergo a certain amount of contraction attended by the forma- 
tion of a finely nodular surface, and section shows dark red markings 
on a light background, from whence arises the name "nutmeg liver." 

Symptoms. — The essential symptom is increase in size as recognized 
by palpation or percussion, with especial reference to the lower border, 
or lacking this, increased density associated with a certain amount of 
pressure tenderness particularly over the left lobe, the secondary symp- 
toms (such as chronic gastric catarrh and intestinal disturbance), and 
the existence of a primary cause. Ascites may or may not be present, 
according to the degree of change produced and hrcmatemesis is rare. 

TUMORS OF THE LIVER.— Primary malignant disease of the 
liver whether sarcomatous or carcinomatous is excessively rare. Sec- 
ondary carcinomatous growths are common, sarcoma most unusual. 

Secondary Carcinoma. — Most often follows involvement of the 
stomach, pancreas, kidney and intestines, and usually first appeals in 
the right lobe. As the process advances, the nodular masses tend to 
soften and become umbilicated by central absorption, tin's condition 



Blood. 



r I Horo- 
scope. 

Explore 
tion. 



Secondary, 



Nutmeg 
liver. 



I rimary 
r;iro. 



Module: 



3oo 



MEDICAL DIAGNOSIS. 



Habitat. 



The 

parasite. 



Points of 
entrance. 



Convey- 
ance. 



Tumor. 
Hooklets. 



Percussion 
thrill. 



being oftentimes distinctly palpable. Cystic Tumors are rare, and 
usually small. They ordinarily originate in the gall ducts, and yield 
a clear or slightly yellow fluid. 

PARASITIC INVOLVEMENT.— The amoeba coli is the cause of 
practically all tropical abscesses, being found sometimes, even in the 
absence of dysenteric symptoms. The echinococcus is the most im- 
portant of the various other forms of parasites encountered. 

ECHINOCOCCUS CYSTS.— These are due to the embryo 
of the taenia echinococcus, a tape worm, which is rarely encoun- 
tered save in Ireland and Australia, though found occasionally 
in Germany, and now and then met with amongst the Icelanders 
who have settled in British Columbia. The worm is not more 
than a quarter of an inch in length, and belongs properly to the 
dog. It is composed of three or four segments, 
the mature terminal portion being about 2 mm. 
long and 0.6 mm. wide, yet it contains several 
thousand eggs. The head shows a rostellum, 
4 suckers and 2 rows of hooklets; the embryo 
provided with six hooks and arranged in 
pairs, makes its way through the intestinal wall 
and may enter the portal vessel and be carried 
from the liver and the systemic vessels by 
which it reaches the brain or other distant 
organs, or it may remain in the peritoneal 
cavity or the surrounding muscles. It is 
thought that this embryo may find entrance 

through infected dust as weU as through E ^ hinococcus - < Braun -> 
drinking water and in Australia and Iceland where the disease is most 
prevalent, the dogs are very generally infected and the relation between 
them and their masters is very close. 

General Symptoms of Hydatids. — Diagnosis primarily depends 
upon the presence of a cystic tumor and upon the recovery of hooklets 
from fluids discharged or obtained by puncture. The presence of 
hydatid disease in other portions of the body is of course sugges- 
tive. In the liver, the symptoms are more distinct, owing to the fact 
that these cysts when superficial give upon percussion a peculiar 
vibration known as the "hydatid" thrill. See page 230. They may 
be large, and, in this location, produce various pressure symptoms, 
or pyemic symptoms should they suppurate. Such cysts like hepatic 
abscesses may rupture in almost any direction. 




Fig. 



-Taenia 



DISEASES OF THE LIVER — CIRRHOSIS, 



30I 



CIRRHOSIS OF THE LIVER.— The central factor in all 
forms of cirrhosis of the liver is the increase of connective 
tissue, and the term is a general one, applied to similar changes 
in other organs. We have clinically to deal with four vari- 
eties. (1st). Laennec's cirrhosis; the common form of the 
disease as encountered in every clinic. (2nd). Hanot's cirr- 
hosis. (3rd). Syphilitic cirrhosis. (4th). Chronic perihepatitis or 
capsular cirrhosis. The cirrhosis due to chronic disease of the heart or 
lungs, (nutmeg liver), is discussed under chronic hyperemia, and large 
numbers of minor forms of some pathologic and etiologic interest 
need not be discussed in this volume. Etiology. — Certain of the infec- 
tions, both acute and chronic may result in cirrhotic changes. Chronic 
obstruction of the bile ducts, chronic passive hyperemia and anthracosis 
are to be numbered amongst the etiologic factors. Alcohol is the one 
really important cause of Laennec's cirrhosis, the form of predominant 
interest and frequency of occurrence, and information concerning the 
extent and duration of alcoholic indulgence is prerequisite to diagnosis. 
Gout, lead poisoning and the excessive consumption of highly spiced 
and over-rich articles of food, though contributive factors, are seldom 
of primary importance. It follows then that lacking a history of pro- 
longed use of alcohol, a positive diagnosis of Laennec's cirrhosis will often 
prove erroneous, while on the other hand, a knowledge of previous alco- 
holic indulgence, even though moderate, may suggest the proper explan- 
ation for many obscure gastro-intestinal symptoms. Morbid Anat- 
omy. — True atrophic cirrhosis, or "gin drinkers' liver" is small, hard, 
resistant to the knife, and irregularly lobulated or nodular. The little 
nodules may, by the contraction of the fibrous bands, become promi- 
nent, and thus form the "hobnail liver," so called from its resemblance 
to the hobnail shoe. The color is yellow, and the cut surface is mottled 
with color running from yellow to brown. Microscopically, the changes 
consist in the formation of new connective tissue around the sheath 
of the veins, and this, contracting, causes compression of the portal 
capillaries, portal obstruction, and, therefore, congestion of all the terri- 
tory normally drained by the portal vein. It is this chronic passive 
congestion which produces most of the clinical symptoms of the disease. 
such as ascites, chronic catarrhal gastritis, enteritis, haematemesis, blood- 
ing hemorrhoids, and, that distension of the superficial abdominal veins 
known as the Caput Medusae, this last symptom appearing, usually, it" at 
all, after the oncoming of asoitos, which IS a direct and important 
contributory factor. Hypertrophic Cirrhosis. Called also hepatog- 



Four 

varieties. 



" Nutmeg 
liver." 



Many 
factors. 



Alcohol the 
chief. 



A diagnos- 
tic aid. 



" Hobnail 
liver." 



Source of 
symptoms. 



3° 2 



MEDICAL DIAGNOSIS. 



Biliary 

form rare. 



Probably 
an infec- 
tion. 



Habits. 



Congestive 
symptoms. 



Late recog- 
nition. 



Physical 
signs. 



Pre-atro- 
phic stage. 



Value of 
palpation 

variable. 



enous and biliary, it is a comparatively rare form, and is character- 
ized by a general increase in size and less firm resistance to section 
than is present in the atrophic form. Both the outer and the cut sur- 
faces are comparatively smooth and the term unilobular as opposed to 
multilobular is applied to this condition, because of the involvement of 
individual acini rather than of groups. The process is practically a 
pericholangitis and there is much evidence to support the theory of 
direct infection as the primary cause. Perihepatitis or Capsular 
Cirrhosis. — This is merely a chronic capsulitis, the liver substance 
taking little or no part in the process. The same process in the spleen 
and peritoneum is said to be an almost invariable accompaniment, as 
is chronic interstitial nephritis. Osier describes two classes of cases, 
one associated with the ordinary 7 symptoms of cirrhosis, the other with 
adherent pericardium and chronic mediastinitis. 

Symptoms of Laennec's Cirrhosis. — A diagnosis of the ordinary 
form of cirrhosis of the liver depends ordinarily to an unusual degree 
upon the knowledge of the patient's habits and the proper interpretation 
of secondary symptoms. Given any case presenting a history oj immod- 
erate or even moderate alcoholic indulgence extending over a period 
of many years and showing symptoms of chronic gastric catarrh, 
chronic catarrhal enteritis, even without hemorrhoids and hcematemesis, 
the diagnosis of an existing hepatic cirrhosis should always present 
itself. The disease is seldom recognized until well advanced, but this 
is no doubt due in many instances to a failure to appreciate the value 
of grouped diagnostic factors. The physical signs of the disease may 
or may not be well defined. By auscultatory and direct percussion and 
by palpation one may usually make out a decided shrinking in the 
hepatic outline, and, especial stress should be laid upon the fact that the 
early shrinkage is most marked over the left lobe. The spleen is 
moderately enlarged in 75 or 80% of all cases, another factor of great 
importance. The so-called pre-atrophic stage of engorgement is so 
seldom positively determined that it might as well be discarded as 
unproven. Another fallacy is that pertaining to the direct recognition 
by palpation of the hobnail projections on the liver surface. These 
can rarely be felt, and no stress should be laid upon negative findings. 
When the liver can be palpated, the sharp firm edge indicating 
induration is most suggestive and valuable. A co-existent ascites 
ordinarily makes it impossible to accurately palpate either the liver or 
spleen and in any such case the best opportunity arises immediately 
after the aspiration of the ascitic fluid. The so-called "dipping" method 



DISEASES OF THE LIVER — CIRRHOSIS. 



3°3 



so often recommended, which consists in burying the fingers by a sharp 
stroke upon the abdominal wall in order to displace the fluid and meet 
the descending liver edge in inspiration is usually futile. The Caput 
Medusa, so called from its fanciful resemblance to the Medusa head is 
formed by the enlargement of the superficial lateral veins of the abdomen, 
and when present is a symptom of much interest and importance. 
Every clinician must realize, however, that it is a comparative rarity, 
moreover, it is often confounded with the general distension of the 
superficial abdominal veins met with in various conditions producing 
pressure and obstruction in the abdominal circuit. It should be kept 
by itself as a clearly defined symptom, as the veins which represent the 
Medusa locks are the lateral veins joining the axillary and the femoral, 
and possess a curious valvular arrangement, which normally directs 
blood flow from above the umbilicus to the axilla, and, below it, to the 
femoral veins, but, in the presence of any marked obstruction, permit a 
direct upward flow. To summarise : — the diagnosis of atrophic cirrhosis 
must rest upon some or all the following data: — (a). A history 0} high 
living, over-feeding, and in nearly every instance alcoholic indulgence. 
(b). Loss of appetite, morning nausea and vomiting, irritable stomach, 
excessive fermentation, constipation or intermittent diarrhoea, and 
various other symptoms of chronic gastric or intestinal catarrh, (c). 
The recognition of a shrunken, hardened liver and enlarged spleen. 
(d). Loss of weight, strength, activity and color (a ruddy color may 
persist until late in the disease), (e). Hemorrhoids, blind or bleeding, 
(f). Ascites, (g). Hcematemesis. (h). Jaundice. This last is an un- 
usual symptom in atrophic cirrhosis, though sometimes met with during 
the last months in a form so extreme as to produce a color strikingly 
like that seen in Addison's disease. It must never be forgotten that 
the ascites of atrophic cirrhosis ordinarily precedes any marked general 
edema or anasarca and remains usually for a long period quite alone or 
associated with a moderate edema of the lower extremities due to 
pressure exerted by the ascitic fluid. These cases furnish some typical 
examples of the "poached egg belly." 

Prognosis. — The disease is slowly progressive and beyond thera pon- 
tics though the cessation of the use of alcohol, or of any other habits 
of a similar nature, and a thoroughly hygienic life will do much to 
lengthen the patient's term. 

Differential Diagnosis. Simple atrophy of the liver. This con- 
dition accompanies various cachexias, characterized by profound exhaus- 
tion and marasmus, is suggested by such conditions, and, is of no clinical 



" Dipping. 



Seldom 

marked. 



Veins 
involved. 



Diagnostic 
summary. 



Edema 

slight. 



InourabU 



Unim- 
portant. 



3°4 



MEDICAL DIAGNOSIS. 



Readily 
recognized. 



Often seen. 



Suggestive 
course. 



Exudates 
and transu- 
dates. 



Rare. 

Marked 

icterus. 



Urine. 



Two forms. 



Nodules. 



Latent 
cases. 



Therapeu- 
tic test. 



interest or importance. Nutmeg liver. An atrophic nutmeg liver 
may give rise to much difficulty, but the preexistence of disease of the 
lung or heart, and the fact that it does not present a primary ascites, 
but one secondary to a general anasarca, usually suffices for its differ- 
entiation. Fatty cirrhotic liver A very considerable number of the 
cases of cirrhosis that we meet with are fatty livers, a form easily rec- 
ognized by palpation, the organ being enlarged and of firm consistence. 
It presents no essential difference in symptomatology from that of the 
ordinary atrophic form. Portal phlebitis and thrombosis. The diagnosis 
of this condition depends chiefly upon the existense of a potent cause 
such as ulceration, gall stone and suppurative diseases and generally the 
condition is suggested by a very rapid onset of ascites, splenic enlarge- 
ment, and the other symptoms of portal obstruction, together with their 
rapid recurrence after paracentesis, though this sometimes occurs in 
true cirrhosis. The specific gravity of the clear ascitic fluid is nearly 
always below 1015 in the case of cirrhosis, whereas, in chronic peri- 
tonitis it is distinctly turbid, and in ovarian cyst, of higher specific 
! gravity and containing a greater amount of albumin. Hyperthropic 
Cirrhosis (Hanot's disease, biliary cirrhosis). — This is a compar- 
atively rare ailment, and can hardly be confounded with true cirrho- 
sis, the spleen is enlarged, icterus is intense, and the secondary 
symptoms of portal obstruction are entirely absent, ascites if occurring 
at all, coming on late as a part of the general cachexia. The color 
of the stool shows an intermittent bile secretion, the urine is abundant 
as contrasted with that of atrophic cirrhosis, and contains bilirubin. 
The disease is one of long duration, lasting on the average from five 
to ten years. Syphilitic Cirrhosis. — This disease may assume either 
an atrophic or hypertrophic type and represents a genuine interstitial 
syphilitic hepatitis. As seen in the adult it is atrophic, in children, 
ordinarily hypertrophic. A positive diagnosis is never possible, but is 
rendered probable by the history or marked evidence of syphilis. 
Syphilitic Gummata of the Liver. — These may occur at any age, as a 
result either of congenital or acquired syphilis, and, varying greatly in 
size. The clinical picture is that of hepatic cirrhosis, but after the 
removal of any ascitic fluid that may be present, the nodular outline 
of the liver is often appreciable. Certain cases show a peculiar latency 
I as regards general symptoms, though representing marked and easily 
recognizable tumor. The most important clinical inference is that when 
one meets with a nodular liver, with or without symptoms of cirrhosis 
or history oj syphilitic injection, he should apply the therapeutic test of 



DISEASES OF THE LIVER — JAUNDICE. 



305 



mixed treatment, and indeed this should be applied in practically 
all cases of solid growths in the abdominal region. Amyloid 
Liver (amyloid degeneration of the liver). — This condition is 
invariably secondary to some severe derangement of metabolism, 
especially those associated with chronic septic absorption, as caries 
of bones and pulmonary tuberculosis of the advanced type. It 
may also be the result of chronic and neglected syphilitic infection. 
The liver is large, smooth, and all symptoms of portal obstruction 
are absent. Icterus is seldom present. The disease is invariably 
fatal. 

CATARRHAL JAUNDICE {acute catarrh 0} the bile ducts). — 
This is essentially a part of a catarrhal gastro-duodenitis and is actu- 
ally an obstructive jaundice, due to inflammatory products and swelling. 
It is especially common in children but may be met with at all ages in 
connection with acute or subacute indigestion or a large number of 
diseases associated with a tendency to catarrhal inflammation of the 
upper intestinal tract. It sometimes seems to be epidemic and due to 
acute infection. Save for the evidence of jaundice (color, light 
pasty stools, etc.) it may be wholly symptomless, or, especially 
in the epidemic form, there are symptoms of indigestion associated 
with mild fever and general malaise. The liver is usually slightly 
enlarged but the spleen rarely tumefies. Duration is from 2 to 12 
weeks. Chronic catarrhal jaundice is merely an expression of chronic 
obstruction, due to any of the causes described on the preceding 
page. It may be complete or incomplete, persistent or intermittent, 
and will be discussed further under cholecystitis and cholelithiasis. 

ACUTE CHOLECYSTITIS.— In from 15 to 20% of the cases a 
cholecystitis exists without gall stones or other causal indications. The 
flora of the disease include a pyogenic staphylococcus, steptococcus. 
pneumococcus, colon and typhoid bacillus. 

Symptoms. — It should be stated emphatically that jaundice may 
or may not be present and that the pain may be distinctly localized 
in the region of the lip of the gth costal cartilage, over the gall-bladder 
itself, or, may first be referred to the epigastrium or even to the region of 
the appendix. Pain is also felt usually under the right scapula or 
even in the right shoulder. There are nausea, vomiting, rapid pulse. 
fever, prostration, local tenderness and rigidity which in most cases 
become definitely localized. 

CHOLELITHIASIS.— Gall stones may be single or present by the 
hundred or thousand (usually from 5- 10 or 12 are met with). They may 
20 



Secondars . 



Large 

smooth 
liver. 



Icterus. 



Epidemic 
form. 



Mild 

symptoms. 



Jaundice 
and pain, 
variable. 



3°6 



MEDICAL DIAGNOSIS. 



Size and 
form. 



Structure 
and con- 
stituents. 



Latent 
cases. 



Colic. 



Tender- 
ness. 



Cystic duct 

vs. 
Common 
duct. 



Chief 

symptoms. 



Dietl's 
crises. 



Illustrative 
case. 



vary in size from mere grains to stones measuring six inches or more in 
length, are polygonal with smooth facets, more rarely smooth, ovoid or 
round. They have a nucleus, usually of bile pigment and germs 
have been reported and undoubtedly are actively concerned in the 
processes leading to their formation. Section shows laminated struc- 
tures with radiations and an analysis reveals biliary and fatty acids, 
magnesium and calcium salts and even traces of iron and copper. 
Cholesterin constitutes the bulk of the stone, their color is brown and 
the surface may be rough and mulberry like. Autopsies show an 
astonishingly large number of cases of gall stones* and have proven 
that during life they have in many instances yielded no symptoms save 
probably "indigestion," "flatulence" and the like. Ordinarily their 
migration into the ducts gives rise to biliary colic. This is character- 
ized by violent and abrupt pain in the right hypochondriac region or 
epigastrium-, radiating to the shoulder blade with vomiting, sweating, 
circulatory depression and usually intermittent fever which may be pre- 
ceded by a sharp chill. The localized tenderness and muscular rigidity 
tend after a time to become localized in the region of the tip of the ninth 
costal cartilage, the liver and spleen may be enlarged, and the urine 
frequently contains albumin. If the stone be in the cystic duct there 
is no jaundice, or but a suggestion of it indicating complicating cholan- 
gitis; in the common duct, persistent and severe obstructive, or, slight 
transient jaundice. f These attacks may be repeated until the stone 
passes onward or backward or is removed by operation, and death 
rarely occurring during an attack, though phlegmon, rupture and gen- 
[ eral peritonitis are possible. The location of the pain in the upper 
abdominal and lower thoracic segment with localized tenderness (best 
elicited by deep pressure in full inspiration) and perhaps a history of 
previous attacks are the chief distinguishing symptoms. If jaundice 
co-exists the diagnosis is almost absolute, yet the author has reported a 
case of floating kidney, associated with Dietl's crises during which 
jaundice occurred and operation revealed a normal gall-bladder. A 
second case of floating kidney in which the same condition without 
jaundice existed and proved to be due to gall stones. A case more 
recently observed showed no tenderness over the liver or gall-bladder 



* Autopsies also demonstrate the tendency of unoperated cholelithiasis to 
lead to carcinoma of the gall-bladder — the latter disease being seldom 
found without the former — but this does not apply to operated cases. 

fMany stones are of the "ball valve" variety, persistent obstruction 
not being maintained. 



DISEASES OF THE GALL-BLADDER— CHOLECYSTITIS. 



307 



even under forcible deep upward pressure in deep inspiration and the 
pain was invariably left sided. The stools should be carefully examined 
during and immediately after a supposed attack. Gall stones, chole- 
cystitis or adhesions may alike give rise to recurrent attacks of more or 
less severe pain and an old gastro-duodenal ulcer may through the 
same cause be associated with symptoms hardly distinguishable from 
those of gall stones. 

Obstruction of the Common Duct. — Obstruction may be abso- 
lute with profound and persistent jaundice (pale stools, etc.) and be 
due to one or several stones, or it may be only partial with remittent 
jaundice or a so-called ball valve stone producing paroxysmal chills 
with fever and sweating, persistent but variable jaundice, intensified 
during the paroxysm, hepatic pain and indigestion. Suppuration 
may or may not complicate common duct stones and empyema of 
the gall-bladder and even hepatic abscess or perforation may occur. 
It would be indicated by a more persistent fever, remittent rather than 
intermittent, more marked enlargement of the liver and leucocytosis. 

Cystic Duct. — The chief features of cystic obstruction are the absent 
or slight jaundice, the distension of the gall-bladder, which may reach 
an enormous size, and, the common occurrence of a complicating chole- 
cystitis occasionally of the suppurative type with empyema of the gall- 
bladder. Calcification of the walls and atrophy may occur though less 
frequently than in common duct stones; in some cases is so complete 
as to leave hardly a trace upon superficial examination, as in a case 
seen by the author in which a careful dissection was required and 
revealed the presence of a large number of stones apparently embedded 
in the hepatic tissue. Fever is less often present than in stone of the 
common duct. 

General Comment. — The utmost .difficulty may be experienced in 
both acute and chronic forms of cholelithiasis or cholecystitis and the 
greatest stress must be laid upon the location of the pain and presence 
of localized tenderness, irrespective of jaundice which of course greatly 
assists the diagnosis when present. A palpable gall-bladder moves 
with respiration, has its point of attachment in the region of the ninth 
costal cartilage and is movable only in the segment of a circle whose 
centre is its attachment. It should be noted that jaundice of marked 
degree is absent in obstruction of the cystic duct and a distended gall- 
bladder is rare in obstruction of the common duct. Stone in the com- 
mon duct is usually associated with a contracted gall-bladder; in the 
cystic duct with distension; in malignant disease blocking the common 



Stool-- 



Mislead int.' 
conditions. 



Septic 
crises. 



Ball valve 
stones. 



Septic 

angioctho- 

litis. 



Enlarged 
gall-blad- 
der. 

Atrophy. 



Often 
obscure. 



Pain and 
tendernei 



Tumor. 

Jaundice. 



3 o8 



MEDICAL DIAGNOSIS. 



Malignant 
cases. 



A clinical 
curiosity. 



Progress- 
ive icterus 



Variable 
fever. 
Profound 
exhaustion, 

Shrucken 

liver. 

Urine. 



Phos- 
phorus. 
Luminous 
vomitus. 



Riedel's 
lobe. 



duct with distension,* profound and persistent jaundice, slight or no 
pain. Finally: — All degrees of pain, fever and tenderness may be 
encountered. 

ACUTE YELLOW ATROPHY.— {Icterus gravis. Malignant 
jaundice.) 

Etiology. — This excessively rare disease chiefly affects women and 
falls mostly upon the third decade. It is frequently associated with 
pregnancy, has followed profound emotion or shock, syphilis, alcoholic 
excess and various other ill-determined factors. 

Morbid Anatomy. — The liver cells are necrotic, and there is a gen- 
eral catarrh of the finer bile ducts associated with hemorrhages between 
the liver cells. The organ itself is greenish yellow, greatly shrunken, 
flabby, with a loose capsule, and on section it is mottled with yellowish 
brown and red. The heart may show fatty degeneration, the spleen is 
usually enlarged and the kidneys may also be degenerated. Symp- 
toms. — The picture is primarily that of a catarrhal jaundice succeeded 
in a few days or perhaps two or three weeks by vomiting, perhaps 
bloody subcutaneous and mucous hemorrhage, headache, delirium, 
muscle tremor and sometimes convulsions. The jaundice deepens with 
the onset of the graver symptoms. There is usually no fever, rarely a 
marked pyrexia. The general condition is that of the typhoid state 
and the condition terminates ordinarily in coma. Shrinkage of the 
liver may greatly reduce or entirely obliterate its normal area of dul- 
ness. The urine contains bile, frequently albumin, albumose and casts. 
Leucin and tyrosin are frequently but not constantly present, the stools 
are clay colored, urea is diminished but ammonia nitrogen is increased. 

Differential Diagnosis. — The interesting symptom group differ- 
entiates this disease from all others except phosphorus poisoning, in 
which the three leading symptoms, viz. : — hemorrhage, profound jaundice 
and shrinkage of the liver may occur. The examination of the vomitus, 
and history of the case are the chief distinguishing points. Grave 
symptoms may occur in connection with other diseases associated with 
jaundice but the picture of acute atrophy is seldom present. 

WEIL'S DISEASE {acute febrile jaundice).— -This disease is with 

* The linguiform process of Riedel and Cruveilhier (Riedel's lobe) is 
especially common in chronic disease of the gall-bladder, though occasion- 
ally present in other abdominal ailments (Moynihan). It may lie to either 
side of or over-lay the gall-bladder and is clinically a small freely movable 
but attached linguiform body — which lacks pendulum motion — may be felt 
through with the hand at the back and has a sharp edge. (J. U. Goodrich 
and W. A. Dennis, personal communication.) 



i 



DISEASES OF THE ESOPHAGUS. 



309 



Peculia: 
feature. 



difficulty distinguished from an acute catarrhal duodenitis of the 
severe epidemic type. It occurs chiefly amongst butchers and is ordi- 
narily a disease of warm weather. Affects young and middle-aged 
adults, and is characterized by early jaundice, tenderness and tumefac- Symptoms, 
tion of the liver and spleen, severe headache, and pain in the legs, arms 
and lumbar region, and, oddly enough, in the masseter muscles. The 
stools are often light as in actual obstructive jaundice. The disease 
lasts for a week or two, the temperature is septic in type, and may be 
moderate or high and albuminuria may be present. 

Differential Diagnosis. — The peculiar symptom complex just 
described, offers the only means of differentiation from the ordinary acute 
catarrhal duodenitis. Malaria in its remittent form would show the 
parasite in the blood, phosphorus poisoning by the history of its inges- 
tion, and the phosphorescent character of the vomit. The disease is 
rare and seldom fatal. 

DISEASES OF THE ESOPHAGUS. 

ACUTE ESOPHAGITIS.— Occasionally occurs as a result of the 
irritation of foreign bodies, the action of corrosive poisons or hot 
liquids, or, in. connection with diphtheria or other acute infections. It 
may also be secondary to malignant disease or an extension of a catar- 
rhal process in the throat. Its symptoms are chiefly dull substernal 
pain and dysphagia with or without spasm. 

Esophageal Strictures and Diverticula.— In the absence of 
paralysis, inability to swallow solid or liquid food demands immediate Dysi 
recourse to the esophageal bougie. True stricture is usually due to cicatri- , explora- 5 
cial contraction following the ingestion of corrosive poisons, syphilis, or, * 
a malignant growth and is rarely congenital. Obstruction from the 
pressure of aneurism or other tumors, or even, it is said, of massive peri- 
cardial effusion may occur. A bougie should never be passed without 
a careful preliminary examination jor possible aneurism or necrotic 
processes and it should be remembered that 9 out 0} 10 strictures in adults 
are due to malignant growths. Strictures may be single or multiple, 
sharply defined or involving the whole tube, but are usually either near 
the cardia or just below the pharynx. No definite information is 
obtainable without the use of the bougie, but as a matter of interest the 
esophageal bruit may be auscultated at the left of the spine. It should 
be heard at the left of the seventh dorsal vertebra within 7 seconds Bruit, 
of the time that a mouthful of water is swallowed, and a delay suggests 
obstruction. The most convenient bougies are those with detachable 



Re ware of 
aneurism. 



3io 



MEDICAL DIAGNOSIS. 



Best 

bougies. 



Technique. 



Fluoros- 
copy. 
Perfora- 
tion. 



Site. 
Symptoms. 



Usually 
secondary. 



Emacia- 
tion. 



Readily 
detected. 



heads of varying size and an elastic steel or whalebone stem. As in 
the passage of a urethral sound and for the same reasons, the larger 
sizes should be first tried and forcible manoeuvres avoided. The patient 
should be asked to breathe deeply with the head thrown far back and the 
spine straight, and without introducing the finger, the bougie is passed 
firmly and expeditiously along down the pharyngeal wall disregarding 
the slight obstruction encountered at the cricoid level. Oftentimes 
the exact position of the stricture may be shown by fluoroscopic exam- 
ination or X-Ray photography in a tolerant patient with the bougie in 
situ. Perforation during the procedure is a rare but deplorable acci- 
dent. Secondary dilatations or diverticula above the stricture and 
hypertrophy of the walls most frequently occur on the posterior wall 
near the pharyngeal junction, i.e. opposite the cricoid cartilage and 
there may be no obstructive lesions. Subjective sensations of reten- 
tion and irregular regurgitation of ingesta lacking gastric juices and 
often fetid, are the chief symptoms. 

Carcinoma of the Esophagus. — Primary carcinoma is rare, most 
cases of obstruction being due to malignant disease extending upward 
from the cardia. The symptoms are those of obstruction associated 
with rapid and extreme emaciation and cachexia. Perforation into 
the mediastinum, aorta, pericardium or pulmonary and pleural struc- 
tures may occur or the spine may be involved. In some of these cases 
the X-Ray gives evidence of positive value as shown by the plates 
on pages 211, 212. 

Esophageal Spasm. — This condition is usually associated with 
functional nervous disease such as hysteria, hypochondria, neuras- 
thenia or more rarely epilepsy and chorea. It is also a symptom of 
hydrophobia and the diagnosis rests upon the recognition of the causa- 
tive factors named and the passage of an esophageal bougie of full calibre 
which meets with only temporary obstruction. Liquids can usually 
be taken but solid food excites spasm. 

Special Instruments. — Many special instruments have been devised 
for direct inspection, exact calibre determination, measuring the capacity 
of diverticula, etc., but few have accomplished much in a practical 
way. A bismuth subnitrate porridge may render diverticula plainly 
visible by the X-Ray. 

URINALYSIS AND DISEASES OF THE KIDNEY. 

General Considerations. — The normal activity of the kidney depends 
upon a propor performance of function on the part of the other related 



t 



URINALYSIS EXAMINATION. 



3" 



organs, as well as upon the structural and junctional integrity of the kidney 
itself. Its remarkable intrinsic nervous mechanism makes it difficult 
to apply rigid rules governing its activity, but it may be said that the 
quantity of urine and inorganic salts depend upon osmotic glomerular 
filtration as affected by blood pressure and volume, whereas the output 
of urea and its congeners is determined by the peculiar selective action 
of the cells of the convoluted tubules. Therefore anything affecting 
the renal structure or circulation, directly or indirectly, must alter the 
amount and constitution of the urine. 

Value of Urinary Examination. — No other secretion or excretion of 
the body furnishes so great and so varied information. It measures 
variations in nutrition and waste and indicates approximately or 
positively many diseases, both local and general, 
poisoning (coal tar products, morphia, lead, 
mercury, chloral, etc.), Bright's disease, dia- 
betes, spermatorrhoea, cystitis, pyelitis, gonor- 
rhoea, oxaluria, lithaemia, the presence of fever, 
a failing heart, typhoid fever, pneumonia, septi- 
caemia, urinary and general tuberculosis, filaria 
sanguinis hominis, dyspepsia, chronic appendi- 
citis, hysteria and impending or established 
jaundice may be mentioned as some of the conditions, either directly 
diagnosticated or strongly suggested by urinary signs. The ordinary 
examination of the urine is largely qualitative, but certain necessary 
quantitative methods involve only a small amount of apparatus and a 
negligible loss of time and all vital procedures may be carried out by 
simple methods whose margin of error is not so great as to vitiate clinical 
results. 

The First Step in the Urinary Examination.— Whenever 
possible one first obtains the total urine for 24 hours as best representing 
the functional activity of the kidney as affected by changes in its structure 
or diseases of related organs. It should be collected in clean bottles, 
the night urine separate from that of the day. The urine passed on 
the first morning is disregarded, all voided for the remainder of thai 
day saved and kept in a cool place and that passed after retiring and 
upon arising the following morning separately collected. In certain 
important renal diseases, notably in interstitial nephritis, the normal 
ratio of day to night excretion is greatly modified or reversed. Ordi- 
narily, the day urine is three or four times greater in volume than that 
of the night, hence any marked variation is suggestive. Of individual 



iltration. 



Selective 
cell action. 



Wide 

scope. 




2.— Gonococcus. 



Qualita- 
tive. 

Quantita- 
tive. 



I ret -'4 

hours 

urine. 



Mow 

collected 



Night 

\ -. 
Day. 



312 



MEDICAL DIAGNOSIS. 



Best single 
specimen. 



Variations. 



Relation to 
color and 
weight. 



Painful. 



Temporary 
and unim- 
portant. 



Persistent 
and patho- 
logic. 



Associated 
conditions. 



specimens, that passed late in the day, preferably after a full meal and 
exercise, is most likely to contain albumin or sugar. Except in suppurative 
disease of the kidney or bladder, that least likely to show abnormalities 
is the early morning urine. 

The normal amount of urine varies from 500-2000 c.c. and this 
variation may be temporary or permanent, depending upon exercise, the 
amount of perspiration, the kind and amount of water ingested, or the 
nervous condition of the individual. The smaller amount represents 
usually diminished ingestion or increased loss of fluid through other 
channels such as free perspiration during hot weather, or a diarrhoea. 
Women drink little water and usually show a small daily total. 

Polyuria. — An increased flow may be temporary or permanent, 
purely functional (psychic, emotional), or due to local or general 
organic disease. The ingestion of large quantities of water or such 
diuretic substances as beer or gin, the use of certain diuretic drugs, 
hysteria, migraine and humidity with low temperature, markedly, though 
temporarily, increase the amount. Persistent polyuria usually indicates 
actual disease, and is encountered in chorea, pyelitis, amyloid kidney, 
interstitial nephritis, and diabetes mellitus or insipidus. Except in 
diabetes mellitus and rare cases of interstitial nephritis * an increased 
flow results in a lowered specific gravity, though in diabetes insipidus 
the total urine shows increased total solids. 

Oliguria. — Pathologic diminution is usually associated with severe 
j acute congestion, various forms of acute nephritis, chronic paren- 
chymatous nephritis in its active stage, or with circulatory diseases 
and conditions producing passive congestion. Amongst these are 
cardiac weakness from any source, cirrhosis of the liver, chronic emphy- 
sema, or pressure due to abdominal growths or a pregnant uterus. 
A marked oliguria accompanies acute infections associated with tox- 
aemia and high body temperature, profuse diarrhoeas or hemorrhages, 
shock or collapse, and in nearly all instances a reduction in the total 
quantity of urine is associated with an increase in coloring matter and a 
heightened specific gravity of the individual specimen. This last may 
be present from various causes even though the total excretion of solids 
is markedly diminished. 

Frequency of Micturition and Dysuria. — Increased frequency 
associated with pain usually indicates disturbance of the renal pelvis, blad- 
der, prostate or urethra, rather than disease of the kidney itself. It may 

* Ogden reports such an instance — Clinical Examination of the Urine, 
1903. The author has never encountered one. 



URINALYSIS— COLOR. 



3*3 



be due to simple concentration and high acidity or more frequently 
urethritis or cystitis. Relatively or absolutely painless increased fre- 
quency may accompany any increased urinary flow, normal or abnor- 
mal, or certain stages of active disease, acute or chronic, of either the 
pelvis or the parenchyma of the kidney. Complete suppression, often 
transient, always serious, may occur either reflexly or in acute or chronic 
disease of the kidney, and has been known to last for a period of 9 days 
before a fatal result ensued. Habitual rising at night to void urine 
may be due to urethral stricture, an enlarged or inflamed prostate, 
gravel, renal or cystic stone, diabetes mellitus or insipidus, malignant 
or tuberculous diseases of the genito-urinary tract, interstitial nephritis, 
insomnia, and rarely habit. 

The Color. — Fresh normal urine varies from pale yellow to yellowish 
red, and all urines may be classified as pale, normal high-colored, 
or dark. Deep color is usually associated with relatively high specific 
gravity and marked acidity; pallor with low specific gravity and lessened 
acidity, or alkalinity, diabetes mellitus furnishing an exception to the 
rule. Indeed so striking is the heavy weight of diabetic urine in con- 
nection with its light color, that a provisional diagnosis is often 
suggested when lifting the tube or bottle. 

Fever Urines. — Are usually high-colored, scant and of high specific 
gravity.* 

Bile. — Greenish, yellowish-green, greenish-brown or deep brown 
urines may contain bile; if so, the foam produced by shaking the 
liquid is yellow. Urine containing bile may, when freshly passed, be 
reddish-brown, but oxidation of the brown bilirubin converts it into 
biliverdin and produces the greenish tinge. 

Brown, Black, Smoky or Red Urines Suggest.— (a). Blood. 
Color red, reddish-brown, smoky, brown, black, (b). Mdancemia 
(melanotic sarcoma). The urine becomes black on standing but does 
not reduce Fehling's solution, (c). Alcaptonuria . Urine becomes black 
on standing and reduces Fehling's solution, (d). Poisoning by coal tar 
products. The greenish-black color is due to hydroquinone and fol- 
lows the excessive use of drugs like carbolic acid, naphthalin, guaiacol, 
resorcin, salol, creolin and lysol. (e). Hccmatoporphyrin. Color of 
port wine or Bordeaux. Green urine. — A green urine results from 
the administration of methylene blue. Blue Urine usually indicates 
a great excess of indoxyl products, as in ileus, cholera ami typhus nut 

* Fever may of course exist in exhausting and wasting diseases with a 
relatively pale color and low specific gravity. 



Painless. 



Prolonged 
anuria. 



Important 

sign. 



Relation 
to color, 
weight, etc. 



1 m port ant 

data. 



3^4 



MEDICAL DIAGNOSIS. 



Pus. 
Fat. 

Chyle. 



Physio- 
logic se( 
ments. 



Fixed 



Volatile 
alkali. 



is rare. Orange and reddish-brown urines suggest rhubarb, senna, 
or chrysophanic acid; yellow, santonin. 

Milky Urine. — Such an appearance is usually due to pus or chyle. 
Pus forms a sediment and is easily detected by the proper chemical 
and microscopic tests. Free fat upon the surface is almost invariably 
due to the local use of some unguent, rarely to extreme fatty degenera- 
tion of the kidney. Chyluria. This condition is rare and almost 
pathognomonic of the Filaria sanguinis hominis. The urine appears 
like milk and no fat-droplets can be detected under the microscope. 

Tests for Fats. — The microscopic or macroscopic examination suf- 
ficies in ordinary cases. Chemic Tests. — Add potassium hydrate and 
ether, shake, decant and evaporate the supernatant fluid. The fat is 
taken up, held in solution and remains after evaporation. 

Fibrinuria. — In rare instances, as in some cases of villous growth 
in the bladder, the urine jellies on standing, or, if less fibrin be present, 
a sticky sediment may adhere to the bottom of the glass. 

TRANSPARENCY. — Normal, undecoinposed urine should be per- 
fectly clear save for a slight mucous nebula floating in its upper 
portion, though, even in freshly passed urine, earthy phosphates or the 
amorphous urates sometimes cause a physiologic sediment, the phos- 
phates being associated with feeble acidity or alkalinity,* the urates 
with concentration and acidity. Heating increases the precipitation of 
phosphates and redissolves urates. Persistent opacity or turbidity is 
pathologic and may be caused by pus, blood, fat or bacteria. 

ODOR. — The peculiar odor is intensified in sharply acid, concen- 
trated urine and distinctly and characteristically modified in alkaline 
urine; the volatile alkali (ammonia) being easily detected if present as 
are indol and skatol in recto-vesical fistulae, the odor of hydrogen sul- 
phide in hydrothionurea, bitter almonds in nitro-benzol poisoning, etc. 

REACTION. — The reaction may be acid, alkaline, neutral or 
amphoteric, i.e. doubly reactive.f // alkaline, the physician should 
determine by repeated tests whether the condition is temporary or perma- 
nent and the alkali fixed (potassium or sodium), or volatile (ammonia). 
Any ammoniacal urine to which a few drops of potassium or sodium 
hydrate solution has been added yields when boiling the odor of am- 
monia. So also immersed red litmus paper resumes its original color 

* Many such urines are really neutral, as shown by a phenolphthalein solu- 
tion, though turning red litmus paper blue, possibly through the release of 
CO 2 from the bases.— (F. C. Wood.) 

t Presumably because of the co-existence of the acid monosodium phos- 
phate and the alkaline disodium phosphate. 






URINALYSIS— SPECIFIC GRAVITATION. 



3*5 



"Alkaline 

tide." 



1 mportant 
facts. 



when dried in the air. A physiologic alkaline or neutral reaction often 
appears two or three hours after a meal especially in vegetarians, in 
which case the alkali is fixed and the condition unimportant; but per- 
sisent, non-dietetic alkalinity is abnormal and urine ammoniacal when 
passed indicates usually disease of the bladder or prostate. A meat 
diet tends to produce acidity; a vegetable diet, alkalinity but quantita- 
tive determination of the acidity or alkalinity is clinically useless. 

SPECIFIC GRAVITY. — For ordinary purposes a clinical urin- 
ometer of the usual type properly graduated for definite temperature 
(usually 15 C.) is sufficient. In testing, freshly passed urines, for 
every 3 C. above the standard for the individual instrument one point Caution 
should be added to the right hand figure of the specific gravity. If 
more accurate results are desired or very small quantities of urine are 
to be dealt with as in urethral catheterization the hydrometer of Saxe, 
one of the pycnometers, or, the Westphal balance, may be readily 
obtained. 

Technique. — In ordinary clinical work the following precautions 
are necessary, (a). The urine must be allowed to cool or proper allow- 
ance made. (b). All air bubbles must be re- 
moved with filter paper. (c). The urinometer 
must be perfectly dry and (d) introduced with a 

i\ little spin to prevent it from adhering to the side 
I of the receptacle. (e). The specific gravity 
\ should be read from the meniscus or true sur- 
L V I face, the observer's eye being at that level; false 
fa \ ff readings result if one reads from above, because 
the fluid rises slightly along the urinometer 
stem. (f). If the amount of urine is small, ap- 
proximate results may be obtained by diluting suffi- 
ciently to float the instrument and multiplying 
the two right hand figures of the specific gravity 
by 2, 3 or 4 according to the amount of distilled water used. 

Factors Determining Specific Gravity. — The normal figures vary 
from 1.012 and 1.024, the average lying between 1.018 and 1.022. 
Hysteria and the use of diuretic fluids or drugs may reduce it to 1.002 
and in disease it varies from 1.002 to 1.060. In general, high specific 
gravity points to large hemorrhages, profuse perspiration, diarrhoea, 
fever, and diabetes mcllitus. Low specific gravity suggests chronic 
Bright's disease (particularly interstitial nephritis), diabetes inspidus 
and, hysteria. As a rule, a low specific gravity accompanies increased 




Imk. 123. — Simple Urin- 
ometer and Accessories. 



Wide 
variation- 




3 i6 



MEDICAL DIAGNOSIS 



Exceptions 
to rule. 



Organic 

vs. 
Inorganic. 



Rough 
methods. 



Note 

carefully. 



Signifi- 
cance. 



Associated 
conditions. 



excretion and a high specific gravity, diminished excretion, but there are 
many exceptions to this rule, many grave diseases being associated with 
scant urine and deficient elimination of solids, whereas diabetes mellitus 
may show an enormously increased excretion with the highest readings, 
and diabetes insipidus an increased amount and low specific gravity 
with an actual excess of solids in the 24 hours urine 

URINARY SOLIDS. — Normal urine in the healthy adult of average 
weight should contain about 60 gms. of solids. Of these about 35 gms. 
are organic and 25 gms. inorganic. A rough estimation of the amount 
of solids per 100c c.c. of urine is made by using the co-efficient of 
Trapp 2.00, or of Haser 2.33 as a multiplier and the last two figures 
of the specific gravity as the multiplicand: e.g. specific gravity 1.020: 
20 X 2=40 gms. per 1000 c.c. Twenty-four hours urine 1500 c.c. 40X 1.5 
=60 gms. Of this, about J is urea which should be separately estimated. 
The principal inorganic substances are: HC1 (9.35 gms.), phosphoric 
acid (2.5), sulphuric acid (2.5), nitric acid (1.0), oxalic acid (0.01 to 
0.02), sodium (8.0), potassium (3.0), ammonia (0.7), magnesia (0.5), 
lime (0.3), iron (0.001 to 0.002). The organic substances are in gms., 
urea (30.0), creatinin (1.0), uric acid (0.7), hippuric acid (0.7). Traces 
of a large number of organic substances including the purin bodies 
make up the balance for the organic group. The pathologic sub- 
stances are the albumins, blood, bile pigment, bile acids, indoxyl, 
acetone, diacetic acid, cystin, leucin, tyrosin, carbo-hydrates, phenol, 
creosol, skatol, urobilin, cholesterin, lecithin, diamins, melanin, fats, 
fatty acids, lactic acid, beta-oxybutyric acid. Of these indoxyl, acetone, 
lactic acid, fatty acids, phenol, creosol, skatol, urobilin and even album- 
inous bodies may be present in clinically unrecognizable or negligible 
traces in normal urine. 

Indoxyl (indican). — This normal urinary chromogen results from 
albuminous putrefaction in the presence of bacteria and if found in 
the urine in excess suggests intestinal putrefaction, septic processes or 
the excessive ingestion of red meat. C. E. Simon reports an excess in 
hypochlorhydria, anachlorhydria and the hyperchlorhydria of certain 
gastric ulcers, and an excess is found in typhoid fever, appendicitis 
(chronic or acute), cancer of the stomach, peritonitis, chronic gastritis 
and similar conditions, reaching its maximum in stasis and ileus. Ob- 
struction in the lower colon or simple constipation does not increase it. 

Test. (Jaffe-Stokvis). — (a). Take equal parts of the urine and 
strong hydrochloric acid. (b). Add two or three drops of a saturated 
solution of sodium or calcium hypochlorite, or of common salt peter. 






URINALYSIS — QUANTITATIVE TESTS. 



317 



Shake. Add 1. c.c- of chloroform, shake thoroughly and repeatedly and 
set aside. The chloroform then shows a depth of color varying with the 
amount of indican present. Potassium iodide if present may yield an 
intense carmine and codeine a reddish purple. The observer should 
establish a normal standard by repeated observations using always 
the same quantities of urine and reagents. A more accurate test 
involves the use of a small amount (not an excess) of lead acetate sol. 
(20%) which removes the urinary pigments in the precipitate. 

Quantitative Tests. — Strauss's method. This involves the use of 
a standard color solution obtained by dissolving one mg. of C. P. indigotin 
in 1000 c.c. of chloroform. This should be carefully sealed and kept 
in the dark. Take of urine 20 ex., add 5 c.c. of lead acetate sol. (20%), 
which precipitates the urochrome, filter. Mix 10 c.c. of Obermayer's 
reagent* with 10 c.c. of filtrate (=8 c.c. urine), add 5 c.c. of chloro- 
form, cork, and shake gently for two minutes. Remove chloroform, 
add another 5 c.c. of same and so continue until no color is 
extracted. Of the chloroform used take 2 c.c. in test-tube, add 
chloroform guttatim until the color corresponds with that of the 
standard solution in a control tube of equal calibre both being held 
against a white background. The total number of c.c. of chloroform 
used both in extraction and dilution represents the amount containing 
1 mg. of indigo. By multiplying the total amount of chloroform used 
for extraction by the amount used to dilute to a standard color and 
dividing by two which corresponds to the amount subjected to dilution 
we obtain the amount necessary for complete standardization of the 
total chloroform used. 

INDOL (excreted as potassium indoxyl sulphate). — When found in 
substance in the urine this suggests recto-vesical fistula; otherwise 
the same statements and test apply as given under indoxyl. 

Test of Indol in Substance. — Cholera red reaction. Add to the urine a 
few drops of dilute sodium nitrite solution and gently pour it down the 
side of a tube containing sulphuric acid. Indol yields a purple color at 
the point of contact, a diffuse pink on shaking and blue green on neutral- 
ization with sodium hydrate. f 

SKATOL (excreted as skatol carbonic acid). — It isworth remembering 
that this substance is especially abundant in cases of tuberculous ulcer- 

* Obermayer's reagent. C. P. HC1 tooo, ferric chloride 2. This forms 
a permanent fuming yellow mixture. Accurate quantitative determination 

is not essential. 

fThis is simple and sufficiently delicate but other tests such as that of 

Ehrlich will show 1 part of indol in 400,000 parts of urine. 






3i8 



MEDICAL DIAGNOSIS. 



Urobilin 
icterus. 



ation of the intestines, gastric or intestinal carcinoma and pneumonia, 
and is not increased in the other diseases showing an excess of indoxyl 
(F. C. Wood). Rosenbach's Test. — Add nitric acid, guttatim, to 
boiling urine; a Burgundy red color with a bluish red foam on shaking 
indicates skatol, a reddish or brownish red is usually due to urobilin. 

UROERYTHRIN.— This normal urinary pigment is increased in 
febrile conditions, gout, various dyspeptic conditions and after excesses 
in food or alcoholics. It gives an orange color to the urine and a 
rose tint to uratic sediments. Test. — Add C.P. sulphuric acid gut- 
tatim to the urine and a carmine red color reaction appears, or, some 
pink urates dried or filtered may yield a bright green color with a 
drop of sodium hydrate solution. 

MELANIN. — This brownish black substance produces a dark urine 
or one darkening upon exposure to the air. This color is intensified 
by the addition of bromine water or ferric chloride. 

UROBILIN. — This or its chromogerr is a normal constituent of 
urine either when freshly passed or as developed by oxidation on standing 
and is probably the stercobilin of the feces. In excess it indicates an 
acute infection, lead colic, hepatic cirrhosis, pernicious anaemia, internal 
hemorrhage, passive congestion as in a weak heart, the ingestion of 
such substances as antipyrin and antifebrin, chloroform inhalation and 
the injection of tuberculin (Wood). It may also be the forerunner 
of, or alternate with, the bilirubin of jaundice constituting urobilin 
icterus, most frequent in atrophic cirrhosis, carcinoma and pneumonia. 

Test. — Treat 50 c.c. of urine with an equal amount of pure ether, 
evaporate and dissolve the residue in strong alcohol; the resulting 
solution should be pale yellow and show a green fluorescence. 

Spectroscopic Test. — Dilute urine if necessary, add a few drops of 
tincture of iodide to each 10 c.c. of urine and the spectroscope will show 
a band between the green and blue if urobilin itself, not its chromogen, 
be present. 

THE OXYACIDS. — These have the same significance as indoxyl 
and have no special clinical importance. 

ALCAPTONE. — This rare substance has no clinical importance aside 
from the fact that it produces a urine which darkens on standing and 
reduces Fehling's solution, though not affecting fermentation, phenyl- 
hydrazin, bismuth and polariscopic tests. 

HYDROCHINON AND PYROCATECHIN.— Both of these sub- 
stances produce a urine which darkens on standing but are of no clinical 
importance. 



URINALYSIS — NITROGEN. 



3*9 



UROCHROME AND H^EMATOPORPHYRIN.— These are con- 
stant normal urinary pigments often associated with urobilin and uro- 
erythrin. The first is the chief yellow or amber pigment, the second 
scant and red. (Urobilin yields yellowish brown and uroerythrin pink.) 
Urochrome is readily precipitated by lead acetate solution leaving a clear 
urine well adapted to spectroscopic examination. Hcemato porphyrin is 
often excreted in excess in chronic users of trional, sulphonal, tetronal 
and the like, the urine being dark brown or black by reflected light. It 
is probably derived from hematin and may be demonstrated by Salk- 
owski's Test. — Treat 30 c.c.of urine with a mixture consisting of equal 
parts of a solution of barium chloride (10%) and cold saturated solution 
of barium hydrate, wash the resulting precipitate with water and again 
with absolute alcohol and shake it up repeatedly with a warm solution 
representing 10 c.c. of alcohol and 6-8 drops of HC1; a red violet color 
results and the solution yields the characteristic double bands of acid 
haematoporphyrin.* 

Creatinin. — This derivative of the ingested meats follows the same 
laws as urea as to variation in excretion, both in health and disease. 
It is easily recognized by the intense red color produced by adding 
a little saturated solution of picric acid and a few drops of sodium 
hydrate (Jaffe's test) to the urine. 

Various other substances of no clinical importance but related to 
the foregoing organic compounds are omitted. 

TOTAL NITROGEN.— Before considering urea and uric acid the deri- 
vation and importance of the total nitrogen excretion should be considered. 
While the total nitrogenous output of the human body involves a con- 
sideration of the feces, lungs and skin as well as the urinary nitrogen, 
the fact that this last represents from 92-93% of the total makes the 
urinary examination the primary consideration. The healthy adult 
on a mixed diet secretes 0.2 gms. of nitrogen per kilo of body weight 
viz. : — from 10 to 15 gms. of nitrogen per day. About 86% of the urinary 
nitrogen is urea.f 8% is derived from ammonia, creatinin, the purin 
bodies and the pigments, while 6% represents hippuric acid and unknown 
substances. The nitrogen excretion measures accurately the varia- 
tions, not merely of nitrogenous intake, but of body waste and hence 
the metabolic processes. Increased by nitrogenous diet an excess may 
nevertheless be retained in part for several days, a fact which has Dot 

* Narrow dark band in the yellow, a broader one between the yellow and 
the green in contact with a lighter band in the yellow. 
t Though this ratio is not constant. 



Useful pro 

cedure. 



Factors in 
excretion. 



Ratio to 

body 

weight. 



Derivation. 



retention. 



3 2 ° 



MEDICAL DIAGNOSIS. 



Not prac- 
ticable. 



Simple 
device. 



Retention 
periods. 



Bright's 
disease. 

Danger 
signal. 



Impor- 
tance great. 



yet been explained. Increased excretion also occurs in acute infectious 
fevers (excepting acute yellow atrophy of the liver), malignant growths, 
chronic infections, pernicious anaemia, exophthalmic goitre, scorbutus, 
the leukaemias, resorption of exudates, diabetes insipidus, phosphorous 
poisoning and indeed in practically all diseases associated with marked 
emaciation, malnutrition or excessive toxic metabolism. Diminished 
excretion occurs in nephritis, diseases of the liver and in convales- 
cence from acute diseases, though in the former if associated with 
marked albuminuria the urine may show an apparent increase if 
the albumen is not removed. In nephritis especially the stomach, 
intestines and skin may take on vicarious activity and the feces 
will show increased nitrogen content. For accurate work, careful 
measurements of the nitrogen intake and of that of the feces, as well as 
urinary nitrogen is necessary and the laborious and time consuming 
process is ill adapted to clinical work. A simpler method is to place 
the patient upon a milk diet with a known nitrogen content, making 
daily estimations and then give a rich proteid meal. The promptness 
of the nitrogenous increase will measure the renal activity and per- 
meability save in certain cases of parenchymatous nephritis, unless the 
disturbing elements of uraemic diuresis and increased excretion intervenes. 
For a description of the chemical processes involved the reader is 
referred to the special works dealing with physiological chemistry. 
UREA. — In the normal individual the urea content varies from 20-30 
gms. in 24 hours. It follows in nearly every particular the laws of total 
nitrogen excretion already given. Women excrete less than men, and 
in vegetarians or poorly fed patients, or those on a milk diet, the amount 
may not exceed 15 gms. a day. As before stated it represents 86% of 
the total nitrogen (vegetable diet 79%, rich proteid diet 87%), there are 
periods of retention lasting several days, and it may be increased by 
certain drugs such as salicylic acid, caffeine, and quinine. In diseases 
of the liver the urea excretion is more greatly diminished than is the total 
nitrogen, leucin and tyrosin being coincidently increased, or, in acute 
processes, an increased ammonia excretion replacing the leucin and 
tyrosin. In all forms of Bright's disease save the early stage of par- 
enchymatous nephritis urea is diminished and also shows marked peri- 
odic variations. It is supposed that retained urea in such instances 
is responsible for the periods of diuresis or diarrhoea so commonly 
seen. A sudden drop in urea is often noted in nephritis of all kinds 
and is a danger signal that cannot be disregarded. The author would 
strongly differ from and indeed, reverse the statement made by certain 



URINALYSIS — URIC ACID. 



321 



Value in 
other con- 
ditions. 



Doremus' 
method. 



writers that in renal disease urea determinations are less important 
than casts and albumin. 

In several cases presenting violent and intractable neuralgias the 
attacks were found to coincide in every instance with periods of low 
urea excretion (6-10 gms. per 1000 c.c). In others indeterminate but 
troublesome gastric symptoms, marked neurasthenia and hypochondria 
were found to coincide with the same condition and in all cases were 
promptly relieved by treatment thus directed. In several instances no 
structural disease of the kidney was indicated by the other urinary 
findings. The estimation of urea is one of the simplest and most Note. 
important of all clinical tests. The most convenient method of quan- 
titative testing is that of Doremus which is sufficiently accurate for 
clinical purposes. 

Description of the Doremus Ureometer.— The Doremus ap- 
paratus is much used and consists of a tube carrying a bulb be- 
low and so graduated that each division corresponds to 0.001 gm. of 
urea as represented by the volume of nitrogen evolved at 65 ° F. There 
is also a small, curved, nipple-capped pipet holding 1 c.c. of urine. It is 
filled with Rice's hypobromite solution* to the mark on the long arm 
of the apparatus, and water added to fill the remainder of the arm and 
the lower part of the bulb. The pipetf is then filled with urine (freed 
from albumin or sugar) up to the c.c. mark, and the point carefully 
introduced into the bend as far as it will go, while holding the measur- 
ing tube perpendicularly, and the contained urine slowly and com- 
pletely discharged. After the evolution of gas is complete the number 
of divisions is read off as milligrams per. c.c. or the result multiplied 
by 100 to obtain the percentage. 

URIC ACID. — Uric acid (0.2 to 0.1 gm. daily). As a sediment, 
uric acid is easily recognized by microscopic examination or by the 
macroscopic deposit of a substance resembling cayenne pepper. The 
conditions favoring a uric acid deposit are: — (a) Concentrated urine; 
(b) high acidity; (c) deficiency of salts and pigment; (d) excess of 
the uric acid; (e) rich proteid diet; (f) pathologic increase of metabol- 
ism. The appearance of such a sediment in a single specimen is sug- 
gestive of lithaemia and should call for further investigation. The 
amount of uric acid in centigrams contained in each litre of the given 

* Sol. T, Caustic Soda 100 and Distilled Water 250. Sol. IT, Bromin i> 
Potassium Bromide 1, Water 8. To make test solution — Take 5 cc of 
each and to the mixture add \o e.e. of water. They keep well. 

f The instrument can now be obtained with an attached hollow arm with 

a thumb screw to hold, measure, and release the amount of mine used. 

21 






322 



MEDICAL DIAGNOSIS. 



Important. 



Clinical 
application. 



urine may be approximated by multiplying the last two numbers of the 
specific gravity by 2.* Any sediment may be tested for uric acid by 
heating with a drop of dilute nitric acid upon a porcelain plate; with 
evaporation a reddish residue appears which strikes a beautiful deep 
red with dilute ammonia. Quantitative test: — There is no accurate 
simple test and the complicated exact tests (Hopkins-Worner, etc.) are 
not adapted to the practitioner's use in view of the slight clinical value 
of the procedure. But one approximate method will be given and 
it, like other quantitative tests, must be applied to a portion of the 24 
hours urine to show an excess of uric acid. 

Heintz's Method. — To 200 c.c. of clear urine add 10 c.c. of C. P. 
HC1 and mix thoroughly. After 24 hours filter through a dry filter 
paper of known weight. Dry and re-weigh. The difference in weights 
represents the amount of uric acid in each 200 c.c. of urine. 

THE PURIN BASES.— These substances are derived chiefly from 
the destruction of cell nuclei, hence, from nuclein. Their estimation 
is difficult and at present, of slight clinicaljmportance. 

URINARY CHLORIDES (10 to 15 gms. daily).— Rough Test. 
— Filter the urine if it be not perfectly clear; remove albumin by boil- 
ing if necessary (a trace does not matter). Prepare a solution of silver 
nitrate and distilled water (silver, 1 part; distilled water, 8 parts). Add 
this, drop by drop, to a portion of the suspected urine, which has been 
treated with a jew drops of nitric acid. A curdy precipitate indicates 
normal chlorides. Milky turbidity or simple cloudiness shows a marked 
reduction 0) the chlorides. No precipitate indicates absence of chlorides. 
The value of this procedure in clinical work arises from the fact that the 
outpouring of a serous or fibrinous exudate in acute disease is associated 
with a marked diminution or total absence of the urinary chlorides. One 
of the first evidences of resolution in lobar pneumonia or of the reabsorp- 
tion of an exudate or transudate being the reappearance of the lost chlorides. 
Their estimation is also of great value in making a differential diagnosis 
between meningitis and typhoid fever, f they being markedly reduced 
in the former, and little affected in the latter disease. They are also 
greatly reduced in acute rheumatism and their disappearance without 
added joint involvement suggests pericarditis with effusion. In normal 
individuals a rapid increase of body weight follows the ingestion and 
retention of the chlorides in quantity, a reduction of weight follows if 

* As a matter of fact neither the ratio of uric acid to urea nor to total 
nitrogen is constant. 

|E. S. Wood (Lecture notes). 



URINALYSIS — PHOSPHATES. 



32.3 



the substance be withdrawn. Chlorides are more or less diminished in 
starvation or a milk diet, in febrile diseases generally and by severe 
vomiting and diarrhoea. // is now believed that the edema of Brighfs 
disease is largely due to the retention of chlorides in the tissues and a 
consequent accumulation of water. This retention is favored by the 
chemical combination formed by the chlorides, the relative impermea- 
bility of the kidney and a poor circulation, hence, it has been suggested 
that in both incompensated heart disease and nephritis the amount of 
sodium chloride ingested should be reduced to the minimum. 

A Simple Quantitative Test (Mohr's) may be used if desired, 
its errors being so slight as not to affect its clinical value. Test. — 
10 c.c. of urine freed from albumin are diluted wih 100 c.c. of water, a 
few drops of potassium chromate solution added (enough to produce 
a yellow color) and the whole placed in a porcelain capsule. This is 
then titrated with a standard silver nitrate solution (AgNO s C.P. 29.06 
gms. to the litre), 1 c.c. of which should precipitate 1 centigram of 
sodium chloride; a permanent and diffused orange color ends the titra- 
tion and multiplying the number of c.c. used by 0.01 gives the amount 
of chlorides present in 10 c.c. of urine. 

The Centrifugal Estimation. — Purdy's method is simple and clin- 
ically sufficient. Test. — Fill one of the graduated tubes with urine to 
the 10 c.c. mark, add 15 drops of nitric acid to prevent precipitation 
of the phosphates (more if the specific gravity be high), add (1-8) 
nitrate of silver solution, mix thoroughly, and centrifugalize at high 
speed for 15 minutes; normal bulk percentage reading is from 10-12 
and each division represents 0.123 by weight. 

THE PHOSPHATES (normal excretion 2.5 to 3 gms.).— Urinary 
phosphoric acid is met with largely in combination with potassium, 
sodium, and ammonium (§), to a less extent with calcium .and mag- 
nesium. It is derived to some extent from tissue and food nucleins and 
is increased under a vegetable diet or a rich proteid intake. The term 
phosphaturia is probably a misnomer representing merely a condition 
of reduced urinary acidity which leads to the constant or almost con- 
stant presence of the phosphates as a precipitate. It is met with chiefly 
in cases of neurasthenia or temporarily in nervous overstrain, and may 
accompany hyperchlorhydria. Phosphates arc readily recognized by the 
methods mentioned on page 339. Their quantitative determination is 
of too little importance to be described here. It should be remembered 
that a phosphatic sediment occurs frequently in normal individuals 
and many " phosphaturias" are little more than the result oi morbid 



Relation to 
edema. 



Phospha- 
turia. 



3 2 4 



MEDICAL DIAGNOSIS. 



Two 

varieties. 



Oxaluria. 



Clinical 

value 

slight. 



introspection and too careful attention to the appearance of the excreted 
urine. In ammoniacal urines both the fixed and the volatile alkali 
combine to form the salts so frequently found in the precipitate. 

THE SULPHATES.— Normal excretion (1.5 to 3 gms.). These exist 
either as preformed or as ethereal or conjugate sulphates. The former 
run nearly parallel with urea while the latter follow indoxyl so closely 
as to justify but slight attention here. These latter are however increased 
by the ingestion of drugs such as creosol or phenol and phosphorous 
and occasionally, without an indoxyl excess. 

THE OXALATES.— Another condition which modern investigation 
has shelved is oxaluria, the diagnosis of which was based chiefly upon the 
presence of calcium oxalate crystals in quantity in the urinary sediment. 
These occur usually as a result of gastro-intestinal disturbance to which 
the symptoms formerly attributed to them are more properly ascribed. 
The relation of the crystals to the formation of calculi and their suggestion 
of disturbed metabolism are the only clinical features of importance. 
Dunlop has shown that their presence indicates about 25 milligrams 
of oxalic acid to 1000 c.c. of urine, but this amount does not'exceed the 
maximum normal. Very frequently they are associated with an increase 
of indoxyl and sometimes with increased ethereal sulphates without 
increase of indoxyl. 

IRON. — This exists in the urine to the amount of 1 milligram but 

; its estimation has no clinical value. 

AMMONIA (normal 0.6 to 1.2). — The proportion of nitrogen 
derived from urinary ammonia to total nitrogen is about 100 to 5 and 
the variation of the two substances under dietetic influence is almost 
parallel. In cirrhosis of the liver ammonia is usually increased as also 
in hyperchlorhydria, pyloric stenosis and acute gastro-enteritis. It is 
diminished slightly upon a vegetable diet and the administration of 
fat not only increases it but causes a corresponding but later increase in 
the urinary acetone and such urine may show beta-oxy-butyric and 
diacetic acids. The methods of estimation are too complicated and time 
consuming for ordinary clinical uses and are therefore omitted. 

ALBUMINURIA. — Normal urine does not contain a sufficient amount 
of serum-albumin to respond to certain clinical tests if these are properly 
made, therefore a reaction under such conditions is pathologic. On 
the other hand the presence of albumin does not prove a nephritis as both 

■ pus and blood yield a portion of their albumin to the urine and any 
hemorrhagic or suppurative lesion within or communicating with the 

j urinary tract may cause albuminuria. Again, the absence of albumin 



Of slight 

importance 

clinically. 



Albumin 

normal 

urine. 



Derived 
albumin. 







URINALYSIS — ALBUMOSES. 325 



suppura- 
tion. 



in a given specimen does not exclude chronic interstitial nephritis, as in 
that disease the urine may be albumin free for long periods or appear Ab 
only at certain times of the day or in definite relation to exertion, mental 
or physical. The mere detection of albumin is but a part of the diag- 
nosis and an estimation of the total urinary solids and urea in the 24 Relative 
hours urine and recourse to the microscope play a larger part.* 

Albumin in this connection means serum-albumin which is usu- 
ally associated with serum globulin which acts the same, has essentially Varieties, 
the same significance and need not be separately tested. The urinary 
mucin seldom disturbs reactions but nucleo -albumin frequently obscures Mucin, 
some of the more delicate tests. This substance is increased after 
over-exertion, in actual inflammation of the urinary tract, especially 
in purulent accumulations, in leukaemia, jaundice and acute infections 
with marked toxaemia. Test. — Nucleo -albumin is readily detected by Xucleo- 
diluting the urine with three times its bulk of water and rendering it 
strongly acid with acetic acid. 

ALBUMOSES chiefly the secondary appear in the urine and have 
some clinical importance because of their relation to suppurative proc- indicate 
esses. Their presence, for example, in a pleurisy would suggest 
empyema; in meningitis, a septic rather than a tuberculous process; 
in a severe intestinal lesion, dysentery or typhoid rather than tubercu- 
lous ulceration; in hepatic disease, abscess or suppurative cholecys- 
titis; in tumors, malignant ulceration. Test. — Secondary albumoses 
are precipitated by acetic acid saturated with sodium chloride 
or the biuret reaction may be obtained as follows: — Remove 
all albumin by treating the urine with sodium acetate and 
then with ferric chloride until it produces a deep red color, neutralize 
carefully with sodium hydrate, boil and filter, repeat if a potassium 
ferro-cyanide test applied to the fluid shows albumin. Nucleo-albumin 
and mucin may also need to be first removed if present in quantity. 
This is readily accomplished by strongly acidulating with acetic acid 
and filtering after several hours. 50 c.c. of albumin free urine are then 
acidulated with HC1 (5 c.c.) and phosphotungstic acid sol. added until 
no further precipitate is obtained, gentle heat is then applied until the 
precipitate shrinks and collects on the bottom of the receptacle. After 
decanting, the precipitate is repeatedly washed, dilute sodium hydrate 

* One oi tlir commonest sources of error arises from contamination o' 
the specimen by Leucorrhoeal discharge or the pus and blood of urethritis, 

less commonly there are fistulous openings, draining abscesses of the sur- 
rounding structures. 



326 



MEDICAL DIAGNOSIS. 






A clinical 
curiosity. 



Changes in 
epithelium. 



Functional 
albumin- 
uria. 



Best tests. 



added and the solution warmed until the deep blue becomes a light 
yellow. After cooling a dilute solution of copper sulphate is run down 
the side of the tube or beaker and a rose color indicates albumose. 

The Bence-Jones' Proteid. — This was formerly supposed to be an al- 
bumose but is as yet a doubtful body. It appears in cases of osteomalacia 
and multiple myeloma and constitutes one of the clinical curiosities. 
Its most characteristic feature is its behavior when heat is applied to 
urine containing it. Commencing as an opacity at 50 C. becomes 
precipitated at about 58 C, and increases up to 70 C. when it begins 
to disappear and at boiling point has returned to its first opalescence. 
Without discussing the theories relating to the causation of albuminuria 
one may say that under certain conditions any or all of the proteid bodies 
found in blood plasma may appear in the urine. 

The Significance of Albuminuria. — Osier aptly covers the whole 
field in saying "the presence of albumin in the urine in any form and 
under any circumstances may be regarded as indicative of changes 
in the renal or glomerular epithelium, a change, however, which may 
be transient, slight and unimportant, depending upon the variations 
in the circulation or upon irritating substances taken with the food, 
or, temporarily present, as in febrile states." We know that albuminuria 
may follow emotional disturbances, violent exercise, cold baths, the 
ingestion of excessive amounts of nitrogenous foods or infections of 
various kinds. In young persons it may be irregularly intermittent 
or occur at definite intervals (cyclical), wholly lacking the general 
and circulatory symptoms of B right's disease. 

Tests for Albumin. — As a result of an extended series of tests under- 
taken by Dr. P. A. Hoff and the author covering both normal and 
abnormal urines he is convinced that for the general practitioner the 
only safe and reliable tests are the heat-and-nitric acid procedure and 
the heat test with acetic acid and brine. Every other test used in his 
experiments gave confusing results when it became a question of deter- 
mining the small traces of albumin yielding a haze but no definite pre- 
cipitate. The nitric acid layer test is also practical and accurate ij 
performed with care and a proper knowledge of its disturbing factors. 
In this connection several other tests are mentioned because of their 
general acceptance by physicians but they are not recommended. 

General Considerations. — The essentials of a clinical test for albu- 
min are (1). Simplicity. (2). A reasonable degree of delicacy. (3). Deci- 
siveness. Simplicity reduces careless or imperfect work to a minimum; 
if one exceeds a reasonable delicacy he finds disturbing reactions in 



URINALYSIS — NITRIC ACID. 



3 2 7 



almost every urine, and finally, a test must be so decisive as to make 
unnecessary the more complicated tests for disturbing urinary proteids 
and permit a positive and convincing opinion. The heat-and-nitric 
acid test as usually applied does not fulfil these requirements. Merely 
boiling the urine coagulates both serum-albumin and nucleo-albumin, 
and precipitates the phosphates. Nitric acid alone coagulates serum- 
albumin, the primary and secondary albumoses, nucleo-albumin and 
the resins, and precipitates urates, if present in excess. The careless 
application of the layer test (Heller's test) may result in the confusion 
of the low-lying or rather, junction point band of albumin with the 
higher stratum of nucleo-albumin or resins, or, the albumin ring may be 
obscured in dark colored urines by the pigment developed at the point 
of contact. Another, but unpardonable source of error lies in the failure 
to hold the lube toward the light but against a black background such 
as the coat sleeve or a book. 

The Proper Application of the Heat-and-nitric Acid. — Clear 
the specimen by filtration or if bacterial (persistent cloudiness is usually 
due to bacteria) by adding barium carbonate, shaking andfiltering. 

HEAT-AND-NITRIC ACID TEST.— If the urine be concen- 
trated, dilute it with from two to three times its bulk of water; if of low 
specific gravity, add -§■ its volume of a saturated solution of sodium 
chloride. Then (a) fill two perfectly clear test-tubes § full of the urine 
and set one aside for subsequent comparison of transparency, (b). 
Boil the upper portion of the liquid in the remaining tube and directly 
after boiling add i or 2 drops of strong nitric acid and 1 or 2 drops 
more if no persistent cloudiness or precipitation appears, (c). Any such 
persistent cloudiness or precipitate is serum-albumin. Caution. Do not 
add acid before boiling nor boil after the addition of the acid* Resins 
may be present and cause opacity if turpentine, oil of sandalwood, 
copaiba and the like are taken and bile pigment may precipitate in 
icteric urines, but both disappear on shaking up with alcohol. 

THE NITRIC ACID CONTACT TEST (Heller's test).— Place 
in a conic glass or test-tube a dram or two of pure nitric acid, and, 
using a pipet, allow the urine to flow gently down the side of the 
inclined glass and upon the surface. If the mouth of the pipet be 
placed against the side of the glass, just above the level of the acid, ami 
a very gentle flow established, the result is extremely clean-cut ami 

*Thc latter procedure especially will often cause the conversion of Large 

amounts oi albumin into a soluble acid albumin as is readily proven by any 
one interested. 



Faulty 
method. 



Disturbing 
factors. 



The test. 



An ex- 
cellent 

method. 



wit 



328 



MEDICAL DIAGNOSIS. 



Site of 
band. 



Time 
required. 



Inferences. 



Mucin and 
resins. 



Useful 
manoeuvre. 



beautiful. Albumin, if present, appears as a band or ring at the junc- 
tion of the two fluids and is more or less distinct in proportion to the 
amount of albumin present. The tube or glass should be set aside as 
several minutes may be required to develop the reaction. Urinary col- 
oring matters appear near the surface of the acid, but usually at a point 
just below the albumin ring, if the test has been properly made. If 
within ten minutes there appears another ring resembling albumin, but at 
a distinctly higher level, one may assume that a relative excess of uric acid 
or acid urates is present, or, that the individual from whom the urine was 
received has fever. * 

Mucin, if present in excess, may form a light cloud in the upper portion 
of the urine, and resins may also be precipitated but are known by their 
immediate disappearance when a portion of the cloudy urine is with- 
drawn by means of a pipet and shaken with alcohol. If space per- 
mitted, much that is of interest might be said of the urinary chromogens 
and pigments. If one wishes to study them the urine should be placed 
in the glass and a considerable quantity of the acid poured rather 
briskly down the side. When this is done, the coloring matters are 
prominently displayed and the albumin ring, if present, is raised to a 
level that nearly corresponds to that of uric acid and acid urates, when 
the test is applied by the first method. 

The heat-and-nitric acid and the cold nitric acid tests as thus 
applied are excellent and quite sufficient for ordinary purposes. 
Of the two, the heat-and-nitric acid test is the more definite and 
positive. On the other hand, the so-called "heat-and-nitric acid test" 
as generally used is fallible and misleading. It will be remembered 
that this method consisted in adding nitric acid, drop by drop, 
while boiling the urine. The following errors may then occur:— A 
small amount of albumin treated with an excess of acid may form a solu- 
ble acid albumin and escape detection, on the other hand, in an alkaline 
or neutral urine with phosphates present in excess, a failure to acidify 
the specimen may result in the formation of a soluble alkali albuminate 
and neither acid nor alkali albuminates are precipitated by subsequent 
boiling. Furthermore, according to Purdy, mucin, globulin and 
albumoses are precipitated by this method. The author recently saw 



Relative 
value of 
tests. 



Faulty 
method. 



Confusing 
reactions. 



* According to C. E. Simon the subsequent appearance of a film-like 
hoar frost on the sides of the glass indicates that about 25 gm. of urea are 
contained in a litre of the urine under examination. Similarly spangles of 
this urea nitrate point to 45 gm., and, the separation of a dense mass to 50 
or more gms. to the litre. It must be remembered that such deductions are 
not of much value unless the specimen be a part of the 24 hours urine. 



URINALYSIS— ACETIC ACID. 



3 2 9 



a case in which a specimen of urine containing 0.25% of albumin was 
reported normal after the application of this test. 
THE ACETIC ACID, HEAT AND BRINE TEST.— First Step. 

— To a portion of the urine submitted for examination that will two- 
thirds fill two test-tubes add two or three (never more) drops of 
acetic acid (50 per cent.). Second. — Filter the amount necessary for A fine test. 
the test until absolutely clear. A single filtration usually suffices; if not, 
the cloudiness is probably due to bacteria, which pass readily through 
ordinary filter paper. They may be easily removed by adding barium 
carbonate, shaking, and filtering. Third. — Set aside a portion of the 
previously acidified filtered urine for comparison. Fourth. — Add to 
the remaining urine one-sixth of its volume of a saturated aqueous 
solution of common salt and fill a test-tube two-thirds full. 
Fifth. — Boil the upper portion thoroughly and compare with the 
unheated specimen, holding both to the light against a black back- 
ground, as previously recommended. Any precipitate or cloudiness 
is due to serum-albumin. The amount of time ordinarily involved 
is trifling, and the test is extremely definite and delicate. 

The only reagents required are: (a) acetic acid (50 per cent.); (b) a 1 
saturated solution of common salt, but the procedure must be carried 
out in the exact order here given. 

The Potassium Ferrocyanide Test.— Into a clean test-tube pour a 
dram or two of acetic acid (50%), to this add twice its volume of an 
aqueous solution of potassium ferrocyanide (1: 20). Shake the mixture, 
and overlay with the suspected urine, as is done in the nitric acid 
contact test. Albumin, if present, appears at once as a band at the junc- 
tion of the two fluids. The full amount of acetic acid must be added.* 

Robert's Test Solution (Hn0 3 1 part, saturated solution of magnesium 
sulphate, 5 parts) may be used as in Heller's test but is if anything too 
delicate and subject to the same elements of error. Spiegler's Test. — 
Is too delicate for clinical work showing one part of albumin in 250,000 
of urine containing abundant chlorides. The tri-chloracetic acid 
test can be made by dropping a crystal into the urine contained in a 
small test-tube. It is extremely delicate, partially precipitates albumose 
and, in concentrated urines, urates as a distinct upper ring. Those 
three may show albumin in all urines, or so nearly so, as to rob the 
finding of a trace of any clinical significance^ 

* Disadvantages. It precipitates albumoses and nucleo albumin. 

fNevertheleSS the author has seldom found a distinct ring with tri-rhlor- 

acetic acid without confirmatory microscopic findings. 



1 



33° 



MEDICAL DIAGNOSIS. 



Simple 
tests. 



QUANTITATIVE TESTS FOR ALBUMIN.— Two simple tests 
suffice for the quantitative estimation of albumin. The first demands the 
use of Esbach's albuminometer; the second requires a centrifuge. Both 
tests are extremely simple in execution and as no physician's office is com- 
plete without a centrifuge and as the Esbach tube is inexpensive and 
easily obtained, no hardship is involved in their application. Esbach's 
albuminometer is merely a glass tube graduated and lettered as shown 
below. This tube is filled to the letter U with urine, if necessary 
previously diluted until its specific gravity is 
1008 or lower, and a solution of picric acid 
(picric acid, 10; crystalline citric acid, 20; 
distilled water, 1000) is added until the 
level of the liquid has reached the letter 
R. A rubber stopper is then inserted, 
the tube is inverted several times to thor- 
oughly mix the urine and test solution and 
is then set aside for from 24 to 48 hours. 



Esbach's 
method. 



Best 

clinical 
method. 



. t 




J 



Fig. 124. 
Fig. 124.- 
ometer. 
Fig. 125.— Electric centrifuge. 



■Esbach's albumin- 



This method is sufficiently 



The albumin is precipitated and its height, 

measured by the numerals upon the scale, 

represents in gms. the amount of albumin 

present in one litre (1000 c.c.) of the urine. 

accurate for practical purposes (although peptones, mucins, etc., if 

present, are precipitated together with the albumin), but is slow, and 

far inferior to Purdy's direct centrifugal method. 

Centrifugal Method.— Fill the graduated tube supplied with the 
centrifuge to the mark 10 c.c. Add 3 c.c. of a 10% solution of potassium 
ferrocyanide and 2 c c. of acetic acid (50%). Mix thoroughly, set aside 
for ten minutes, and, thoroughly revolve in the centrifuge until the super- 
natant fluid is clear and the albumin evenly deposited at the bottom of 
the tube. Each mark represents T V c.c. and corresponds to a bulk 
measure of 1% or -^ of 1% by weight (Odgen).* The old fashioned 
methods of estimation by boiling the urine in a test-tube, or by 
judging the amount by the depth of the ring produced by the contact 
test with nitric acid are useful, but not sufficiently accurate and 
introduce too much of the personal equation. On the other hand, the 
very exact methods of the chemical laboratory are laborious, and 
demand more time than the busy practitioner can give. The follow- 

* If urates are present in excess the supernatant fluid may be replaced by 
boiling water after centrifugalization and the process continued a short 
time longer. 



URINALYSIS — PUS — BLOOD. 



33* 



ing classification is employed by E. S. Wood and Ogden for rough 
work and is based upon the cold nitric acid test performed as fol- 
lows: — An ordinary wine glass is half filled with urine, inclined until 
the liquid nearly overflows and then underlaid with nitric acid, poured 
in as slowly as possible, until it equals one-third of the urine vol- 
ume. If then the wine glass be perfectly clean and placed obliquely in 
front of a dark background, the observer facing the light, they dis- 
tinguish (i) the self explanatory u faintest possible trace" (2). A very 
slight trace, i.e. a faint cloud only definitely seen against the dark back- 
ground, (3) a trace, visible without background, both from the side and 
from above but not concealing the bottom of the glass when so viewed, 
(4) A large trace, i.e. a sharply defined zone but not flocculent nor 
wholly opaque when viewed from above. (Represents about 1-10 of 
I %-) (5) A\ of one per cent, reaction, i.e. a sharp non -flocculent zone 
obscuring the bottom of the glass, (6) \ of 1%, band flocculent and 
opaque, (7) \ of 1%, band dense and flocculent.* 

PUS. — Pus in the urine is readily recognized by chemic or micro- 
scopic tests (see page 342). As a gross sediment phosphates and the 
pale urates may mislead the careless observer, but should never cause 
confusion. Urates are dissolved by heating. Phosphates disappear 
if an acid be added, whereas both the foregoing procedures will increase 
a turbidity due to pus. Chemic Test. — Add liquor potassae to the 
suspected urine and shake the solution vigorously. The persistence of 
suspended air-bubbles and viscidity indicate pus. If the amount 
be very large, or if the liquid potassae be added to the sediment after 
decanting the supernatant fluid, a gelatinous mass results. The micro- 
scopic test is more definite when mere traces of pus are present (see 
page 342). The addition of a drop of very dilute acetic acid so- 
lution to a microscopic preparation clearly brings out the nuclei of 
pus cells under the microscope. 

BLOOD (haematuria, hemoglobinuria). — The color of urine con- 
taining blood in quantity has already been described. In general it 
may be said that acid urines containing considerable blood are dark 
or smoky, and alkaline urines bright red. Oftentimes its presence 
must be detected even though the amount is insufficient to color the urine, 
and moreover mere color cannot be depended upon in any case. For 
the detection of small quantities the microscopic examination, chemical 

* It will be seen that such distinctions require much practice but from 
personal experience in the Harvard Laboratory the author ran attest the 
accuracy there attained. 



Wood's 
method. 



Rough 
estimation. 



Simple and 
valuable. 



Color 
decepti 



33 2 



MEDICAL DIAGNOSIS. 



Smoky 
urines. 



Blood 

vs. 
Pus. 



Clots. 



Localizing 
features. 



Hemoglo- 
binuria. 



tests and the spectroscope are extremely important as the coloring 
matter alone may be present primarily or as the result of fermentation 
changes. The color due to poisoning by coal tar products closely 
simulates the smoky urine of hematuria. 

Heller's Test for Blood. — (a). Boil the urine in a test-tube. (b). 
Add caustic soda and continue the boiling as long as precipitation 
continues. 1} blood be present, the phosphatic precipitate is brownish -red 
and the supernatant fluid, a bottle-green. This test is said to detect i 
part of blood to iooo parts of urine.* 

The Guaiacum Test for Blood. — Shake in a test-tube equal parts 
of old turpentine (or hydrogen peroxide solution) and fresh tincture of 
guaiacum. Pour this mixture gently down along the side of the tube 
so as to overlay the urine. If blood or pus be present a blue band 
appears at the point of junction. If this be due solely to blood, it 
persists when the temperature of the mixture is raised to the boiling- 
point, whereas, if pus alone be present, the color disappears. As often- 
times both are present in the urine, the reaction may lack precision. f 

The Sources of Hemorrhage. — Aside from acute Bright's disease 
or severe acute congestion the commonest sources of blood are urinary 
calculi and new growths. Clots occasionally exist if the blood is from 
the bladder, or small clots may represent the lumen of the ureters. 
Blood from the kidney is usually well distributed and lacks clots, and 
further indications of its source are found in the presence of blood 
casts and fibrinous casts. If from the kidney pelvis, the blood cells are 
thoroughly distributed and associated with the peculiar epithelium of 
that region. It may be due to calculi, acute inflammation or varicos- 
ities, and associated pus points to inflammation whether simple, septic 
or tuberculous. Bladder hemorrhages suggest ulceration, calculi, 
tumors or acute inflammation and, rarely, such parasites as the Filaria 
sanguinis hominis may be found with a chyluria. If from the urethra 
the first jet of urine contains the blood or pus, though if from the pros- 
tatic portion it may appear chiefly at the end of micturition. Acci- 
dental blood may occur especially in the female and must be excluded. 
In haemoglobinuria or methemoglobinuria the blood cells are scant 
or absent and the spectroscope shows the characteristic bands of oxy- 
hemoglobin, reduced haemoglobin or methemoglobin. This condition 



* If the urine be alkaline and its phosphates precipitated one may add 
some acid normal urine before testing. 

t If the slightest trace of copper remains from Haines' or Fehling's test 
in an imperfectly cleaned tube a false reaction will appear. 



i -. 



URINALYSIS — BILE — GLUCOSE. 



33.3 



occurs in poisoning by nitro-benzol, sulphonal, antipyrin, phenacetine. 
naphthol, mushrooms, in severe tropical malaria, and certain cases of 
syphilis, typhus and scarlatina. 

BILE. — Bile acids and bile pigment are both found in the urine 
under certain conditions. Bile pigment, if present in considerable 
quantity is readily detected by the yellow-tinted foam produced by 
shaking. The best simple chemic test is made as follows: — Filter the sus- 
pected urine several times through the same filter paper. Drop fuming 
nitric acid upon the wet paper and watch for the characteristic color- 
play, viz., orange, red, violet and green, the last being the essential 
color. Rhombic crystals of bilirubin are readily obtained by shaking 
up thoroughly with chloroform, decanting and evaporating the chloro- 
form extract. Marechalt's Test. — Overlay a portion of the suspected 
urine in a test-tube with an alcoholic solution of iodin (tincture iodin, 
10 parts; alcohol, 90 parts). If bile be present, a beautiful green band 
appears at the junction point. 

Haycraft's Test for Bile Acids. — Is made by dropping a 
pinch of " flour of sulphur" upon the surface of the suspected urine; 
if the bile acids are present the powder drops to the bottom of the tube. 
This old test has been recently studied by Frankel and Cluzet. They 
find it accurate, sensitive, and as applied to the urine, very definite.* 
The reaction depends upon the disturbance of surface tension and the 
presence of bile acids indicates the presence of hepatogenous jaundice, 
though their absence does not exclude it. 

TESTS FOR GLUCOSE IN URINE.— All clinical tests for glucose 
in solution depend upon the following properties: — (a). The fact that 
when brought into contact with certain oxids, as for example, those of 
copper and bismuth, it becomes oxidized at their expense, i.e., acts as a 
reducing agent, (b). Its ready fermentability. (c). The fact that it is 
dextrorotatory. (See also p. 337. Lactose, pentose, etc.) 

The Copper Tests. — The well-known Trommefs test has been super- 
ceded by better and more accurate methods, but FeJdings solution is 
so widely used as to require a description of the test. This solution 
is distinctly inferior to Haines' modification and is so unstable thai it 
must be kept in two parts and mixed whenever needed for use. 

Fehling's Test. — Directions, (a). Remove albumin by boiling and 
subsequent filtration, (b). Pour into a test-tube one finger's breadth each 



Simple 
tests. 



A good 
test. 



Relative 

value. 



* From personal experience with a large number of " unknowns " a cer- 
tain number of which contained bile, the author is convinced thai this is a 
good clinical test. 



- 



334 



MEDICAL DIAGNOSIS. 



Stock 

solutions 



Test fluid, i of the following stock solutions, which when mixed should form a deep 
\ blue solution. 

Solution A. — Dissolve 34.64 gm. of pure, dry, powdered copper sul- 
phate in 200 c.c. of warm distilled water and add distilled water to make 
500 c.c. of the light blue solution. Solution B. — Dissolve in 300 c.c. 
of hot water 180 gm. of Rochelle salt. Filter. Add of pure caustic 
soda, 70 gm. Cool, and add distilled water enough to make 500 c.c. 
of a colorless solution. Keep in a dark place. 

Heat test solution to boiling point, add ai once 20-30 drops of the 
suspected urine and boil no longer, but in the absence of a reaction set 
aside for from 5-30 minutes, and try the polariscopic and fermentation 
tests, a positive reaction proves nothing but the presence of a reducing 
agent unless the ultimate precipitate is red, not yellow or green. 

Objections to Fehling's Solution. — Fehling's solution as ordinarily 
prepared is open to serious objections: — (a). It is unstable, (b). An 
excess of glucose obscures the terminal reaction by becoming carame- 
lized if boiling is prolonged, (c). It cannot be directly applied to 
ammoniacal urine unless such be especially prepared, (d). A large 
number of substances may reduce its cupric oxid. Such are glycuronic 
and glycosuric acid, alkapton, creatinin, uric acid, and various drugs 
such as benzoic acid, chloroform, chloral, glycerin, the salicylates, 
turpentine, etc. Hence, if one uses Fehling's solution for qualitative 
work, he must bear in mind, that it is more valuable as a negative than 
as a positive test. A urine that does not reduce Fehling's solution is 
free from glucose, but reduction does not conclusively establish its presence. 

Haines' Solution. — A much simpler and absolutely permanent 
copper solution is that of Haines* Application of Test. — Boil a 
few c.c. of the solution gently in a test-tube, add guttatim 6-8 drops of 
the urine, boil gently for a moment only. The reaction is identical with 
that of Fehling's solution. 

Allen's Test. — This is said by Hutchison and Rainy to have the 
following advantages: — (a). Albumin need not be removed, (b).- 
albuminous i Uric acid, creatinin, and like substances do not affect the reaction, 
urines. -r^g test d er j ves {\. s value from the fact that acid solutions of sodium 

acetate precipitate the interfering substances without removing or 
affecting any glucose that may be present. 

Test. — In a perfectly clean test-tube heat 8 c.c. of urine to the boiling 

* Formula: Take of pure copper sulphate 30 grains, distilled water 1 
ounce. Make a perfect solution and add of pure glycerine \ ounce, mix 
thoroughly, add liquor potassae 5 ounces. 



Real value. 



A better 
test. 



URINALYSIS — F E R M KNT ATION TEST. 



335 




n 



point. Pay no attention to any precipitate (albumin). Add 5 c.c. 
of the solution of copper sulphate used in making Fehling's solution 
(solution A, as described). Cool partly. Add 2 c.c. of a saturated 
solution of sodium acetate that has been rendered faintly acid by acetic 
acid. Interfering substances are now precipitated. Filter and add 
to the clear filtrate, 5 c.c. of the solution B used in making Fehl- 
ing's solution. Boil twenty seconds. If sugar is present, the solution 
becomes opaque and green, and deposits, either immediately or after 
standing a few minutes, a fine yellow precipitate. The tests already 
given are placed in the direct order of their convenience and rapidity, 
but the inverse order of accuracy. Yet error will seldom occur if every 
sugar reaction be checked by the one accurate test for glucose, namely: 
THE FERMENTATION TEST.— This test depends upon the 
fact that glucose is a fermentable sub'stance, and practically the only one 
that urine ever contains. (See p. 337.) 

The Test. — The most convenient apparatus is that of Einhorn. 
Each step in the process should be checked by comparison with a normal 
urine; therefore two tubes are required. If 
Einhorn' s saccharometer is not to be had, the 
Doremus urometer tubes will answer the purpose, 
(a). Boil the two specimens for several minutes, to 
drive off any air they may contain, (b). Add to 
each a pinch of tartaric acid in order to main- 
lain their acidity and prevent ammoniacal de- 
composition, (c). Dissolve in each the same 
amount of German yeast (about one-sixth of a 
fresh yeast cake is sufficient). If there be any 
doubt as to the freshness of the yeast, it is well 
to test it with a solution of glucose. The long 
limb of the fermentation tube of the saccharometer or of the Doremus 
ureometer is filled with urine, and the two specimens are placed side 
by side in a warm place. About 24 hours are required for complete 
fermentation and quantitative estimation, but the diagnosis can often be 
made in a very short time, as the appearance of any considerable amount 
of gas proves the presence of glucose. By using Einhorn' s saccharom- 
eter the amount of sugar may be determined with clinical accuracy by 
the scale measuring the volume of gas produced. 

Rougher Method. — Lacking any form of fermentation tube, the 
test may be made by taking the specific gravity of two specimens, to 
one of which yeast is added, and both then are set aside in a loosely 



v> 



Absolute 
test. 



Simple 
apparatus. 



Technique. 



Fig. 126.— Einhorn's 
saccharometer. 



s 

travit] 
method. 



33 6 



MEDICAL DIAGNOSIS. 



Caution. 



Not recom- 
mended. 



stoppered flask or bottle and in a warm place. If glucose be present 
fermentation occurs the specific gravity is lowered and each degree of 
density lost roughly corresponds to one grain of glucose to the ounce 
of urine (0.21 gm. to 100 c.c). The specific gravity should not be taken 
the second time until the urine has cooled to the temperature it had when 
the first estimate was made. 

Quantitative Estimation with Whitney's Reagent.— In addition 
to the previously described tests may be mentioned that of Whitney, 
which is more rapid than the fermentation test, but very inaccurate 
and depends upon the decolorization of an ammonio-cupric-sulphate 
solution. 

Test. — One dram is heated to boiling point and the urine is added 
drop by drop, the mixture being boiled for from three to five seconds 
after each addition. If no change occurs, the process is continued until 
ten or fifteen drops have been added. If sugar be present, the blue 
color begins to fade, and is finally entirely removed, leaving a colorless 
solution. The amount of sugar present is then estimated by the follow- 
ing table: — 



If reduced by Minims. 

1 

2 

3 

4 

5 



It contains to the Ounce. Percentage. 
16 or more grains 3.33 

1-67 

1. 11 

0.83 

0.67 

0.56 

0.48 

0.42 

°-37 

°-33 



8 grains 

5-33 

4 

3.20 

2 67 

2.29 

2 

1.78 

1.60 



If the amount of sugar be large, as indicated by the loss of color 
following the addition of one drop, the urine should be diluted by doub- 
ling or trebling its volume by the addition of distilled water, and the 
result then obtained must be multiplied by two or three as the case 
may be. 

The duration of the boiling period must be neither more than five nor 
less than three seconds. In the author's hands it has proven far inferior 
to the fermentation test. 

The Polarimeter. — Direct estimation of the sugars by this means 
is by far the most satisfactory method, requires no special training but 



URINALYSIS — LEVULOSE — PENTOSE 



337 



the instrument is somewhat expensive. The percentage of sugar is 
read directly from the vernier scale in the clinical instruments such as 
Ultzmann's but it is usually best to decolorize the specimen with lead 
acetate solution; the urine must be albumin free and the containing 
tube dry or if containing water, it should be rinsed out with some of 
the urine to be tested. 

LEVULOSE. — Levulose is abundant in ripe fruits and honey, is ab- 
sorbed unchanged and occasionally appears in the urine, yet it can be 
taken in quantity in diabetes without causing a marked excretion and 
in ordinary glycosuria may replace cane sugar or glucose in the diet. 
Instances of pure levulose diabetes have been reported but they are 
exceedingly rare. If ioo gms. of honey be taken on a fasting stomach 
by a non -diabetic not more than 10 or 15% will show levulosuria but 
in diseases of the liver such as cirrhosis, carcinoma and syphilis the same 
test results in a marked excretion and indeed the substance may appear 
spontaneously in such cases. Test. — The saccharometer (polarimeter) 
should show rotation to the left, but the substance reacts to fermenta- 
tion and Fehling's solution exactly like glucose. For identification 
therefore one must use Seliwanoff's Test. — Add to 10 c.c. of urine 
(showing laevo -rotation) a little resorcin and 2 c.c. of dilute HC1; a 
bright red reaction appears on heating if levulose be present. 

LACTOSE appears in the urine of women after childbirth, not in 
pregnancy and more frequently in those who do not nurse the child 
(80% as against 20%). It is most abundant about the fifth month 
after delivery and seldom exceeds 0.5%. Test. — It reduces Fehling's 
solution and is fermentable with difficulty but whenever any sugar re- 
action appears in women after delivery Rubner's Test should be 
applied: — To 10 c.c. of urine are added 3 gms. of lead acetate, the re- 
sulting precipitate is filtered off and the filtrate heated until it assumes 
a brownish color, and again after the addition of ammonia. The 
appearance of a brick red color and a cherry red precipitate indicates 
lactose if there be more than 0.3%. Specimens of high specific gravity 
should be diluted one-half and less amounts require evaporation of 
the urine and a test of the residue. 

PENTOSE.— After the ingestion of large quantities of fruit, or more 
rarely after taking excessive amounts of vegetables, coffee, tea or milk. 
pentose may appear in sufficient amount to reduce Fehling's solution. 
A very few cases of true pentosuria with otherwise unimportant symp- 
toms have been observed. 77 does not yield gas prod net ion by fermen- 
tation which differentiates it from the more important substance, glucose, 
22 



Technique. 



Important 
data. 



Clinical 
value. 



Misleadini 
reactions. 



Necessary 
test. 



Lactation 
glycosuria. 



Specific 
test. 



Fermenta- 
tion absent. 



. 



338 



MEDICAL DIAGNOSIS. 



Not fer- 
mentable. 



Important 

in 

prognosis. 



Simple 
test. 



Two good 
tests. 



Simpler 
method. 



MALTOSE. — Its chief interest lies in its presence in certain cases 
of pancreatic disease but the tests are not suitable for the practitioner. 

GLYCURONIC ACID.— This substance may in certain combina- 
tions reduce Fehling's solution, but it has no definite clinical signifi- 
cance, does not undergo fermentation with yeast and is levorotatory in 
acid solution. The only definite test is that of Newburg, a description 
of which may be found in the physiological chemistries. 

ACETONE, DIACETIC AClb AND OXYBUTYRIC ACID. 
— One need only consider the two former substances clinically, though 
it is probable that they are derived from oxybutyric acid by oxidation. 
A distinction may be drawn between the diabetes of a severe and that 
of a mild type by the amount of acetone and the behavior of the ace- 
tone and diacetic acid as affected by diet. They are prone to appear 
if the diet is rigidly proteid and disappear when a mixed diet is allowed 
but if they persist in quantity the case is a bad one and the end not far 
distant. The significance of acetone and diacetic acid is essentially the 
same for both, but the former may precede the latter and should be 
sought in diabetic urines if diacetic is absent, the latter being first tested 
for, because of the simplicity of its reactions and because it is invari- 
ably pathological though not confined to diabetes. 

DIACETIC ACID.— Test.— If a few drops of the tincture of ferric 
chloride be added to the urine in the presence of diacetic acid a bordeaux 
red appears together with a precipitate of phosphates. For accurate 
results these should be allowed to settle or be filtered out and the addition 
continued.* The urine must be fresh or the test is of no value. 

ACETONE.— Legal's Test.— Distill a few c.c. of urine by using a 
simple distillation flask with its neck corked and its lateral arm leading 
into a test-tube or ordinary flask; a bunsen burner or alcohol lamp 
completing the outfit. The distillate collected in three or four minutes 
is treated with a few drops of a fresh solution of sodium nitro-prusside, 
a few drops of acetic acid are added and the mixture rendered alkaline 
by sodium hydrate. If acetone be present a red appears deepening to 
carmine and purple red. Lieben's Test. — Add to distillate a few drops 
of Lugol's solution and sodium hydrate. If acetone is present it will 
form a macroscopic or microscopic sediment of the star like yellow 
crystals of iodoform and on heating the characteristic odor may appear. 

THE PRESERVATION OF SPECIMENS FOR EXAMINA- 

* The disappearance or marked diminution of the color on heating sug- 
gests the presence of salicylates or coal tar products which may yield a 
similar reaction. 



_- 



URINALYSIS — SEDIMENTS. 



339 



TION. — Urine must be examined before decomposition or the findings 
are worth little. One need only have the patient add one or two thymol 
crystals, an ounce of cold saturated solution of boracic acid, or sali- 
cylic acid gr. xxx, to the quart of urine to ensure its preservation. For- 
malin is less desirable as it forms a precipitate. 

THE EXAMINATION OF URINARY SEDIMENTS.— The 
accurate microscopic examination and correct interpretation of urinary 
sediments demand a thorough knowledge of the special technique in- 
volved. Gross error is -possible in two directions, i. Through failure 
to detect important abnormal elements. 2. Through misinterpretation of 
elements found. Every physician should not only own a microscope, 
but be able to use it, and no time can be more profitably employed than 
that which is spent in acquiring a correct technique. He, who graduates 
from the schools of to-day, is or should be trained to a degree that will 
enable him to do reasonably accurate work in this line. On the other 
hand, many excellent men of the older generation through lack of early 
training and opportunity are sadly deficient in this important branch 
of clinical medicine. 

Illumination. — In examining a urinary sediment microscopically, 
the first essentials are correct focusing and a comparatively dim 
light. Every microscope should be provided with an iris diaphragm 
and a nose-piece holding three objectives, one low power, one 
medium, and for the third, a high power oil-immersion lens. In 
urinary work only the first two are required, save in those cases in 
which the tubercle bacillus is the object sought. The physician should 
commence operations with a dim light and his low-power lens (1 inch 
or \ inch objective), this being by far the best for finding casts as it dis- 
tinctly shows their outline and gives a larger field. He should then 
slightly increase his light and bring his medium power objective (\ to 
I inch) into focus. This brings out the structure of casts and renders 
distinct any cellular elements or crystals that may be present in the field. 
Having once found any object of interest the lenses and the illumination 
may be varied at will. 

Substances found in Urinary Sediments. — The following are the 
substances most frequently found in urinary sediments:— Extraneous 
Material such as fibers of cotton, linen, wool or silk, various vegetable 
forms from the rinsing water, if it be not distilled, starch-grains, etc. 
Phosphates. The macroscopic appearance of the phosphatic deposit 
is well known. The grayish-white material so often mistaken for pus 
•s composed of amorphous calcium and magnesium phosphates and their 



i Light and 
lenses. 



- 



34o 



MEDICAL DIAGNOSIS. 



ready solubility in mineral acids at once identifies them. They are 
found only in alkaline urine, and, if ammoniacal fermentation has 
occurred, will be associated with beautiful crystals of the triple phos- 
phate. Calcium phosphate may also appear in crystalline form. 





Fig. 127. 
Calcium oxalate crystals. 



Fig. 128.— {Alter Jakob.) a. Cal- 
cium phosphate, b. Calcium sul- 
phate. 



Urates. The ordinary deposit of urates occurs in moderately acid, 
concentrated urine during the process of cooling, or when exposed 
to an unusual degree of cold. The color varies from yellow to rose-red, 
the latter constituting the so-called brick dust deposit (sedimentum 
lateritium). Upon application of heat they promptly disappear. When 




Fig. 129.— Ammonio-magnesium 
(Triple) phosphate. 



Fig. 130.— Uric acid crystals. 



nitric acid is added to a urine rich in urates, a deposit of nitrate of 
urea is formed. The deposited urates are amorphous, excepting only the 
ammonium urate, which occurs in ammoniacal urine as the so-called 
thorn-apple crystals (see fig. 131). 



URINALYSIS — SEDIMENTS 



341 



Uric Acid. — Uric acid may be precipitated from any urine, if concen- 
trated, during the so-called acid fermentation or in hot weather when Signifi- 
the high temperature prevents precipitation of the urates. Excessive deposit. 
acidity and concentration or a pathologic excess may occur in certain 




Ammonium urate. 




Tyrosin. 



conditions, but, when passed, urine should never contain the crystals as a 
precipitate. The macroscopic deposit resembles cayenne pepper. 
The microscopic appearance is best shown by the plate (see fig. 130). 
Calcium Oxalate. — This rarely forms a visible sediment and is 
abnormal if found in urine freshly passed. The crystals are character- 




Fig. [33.— a. Cystin. b. Leucin. 




V\\x. [34.— Calcium carbonate. 
{After Jakob.) 



istic and unmistakable (see fig. 127). Leucin, tyrosin, and cystin arc 
rarely seen, but may be readily recognized by comparison with the 
illustrations (see tigs. 132, [33), 
Calcium Carbonate. This is occasionally precipitated with the 



342 



MEDICAL DIAGNOSIS. 



Erythro- 
cytes. 



Phantom 
cells. 



Leuco- 
cytes. 



Valuable 
device. 



earthy phosphates. Usually it is amorphous, but occasionally forms 
crystals shaped like a dumb-bell. It is easily recognized by the effer- 
vescence produced when a mineral acid is added. 

The Organized Sediment. — The organized constituents of the 
urinary sediments are far more important than the inorganic. The 
chief elements or substances are: — (a). Blood, (b). Pus. (c). Sper- 
matozoa, (d). Bacteria, (e). Epithelium, (f). Casts (pseudocasts, true 
casts). Rarely one may find parasites or their ova and fragments of 
new growths. 

Blood. — The blood as it appears in the urine may be quite normal 
in appearance, or on the other hand be so changed as to make its recog- 
nition difficult. If hemorrhage has taken place in the urethra, prostate, 
bladder, ureters or in the pelvis of 
the kidney, and the urine is acid and 
fresh, the red corpuscles appear as 
yellow biconcave discs, with rounded 
edges and a light central portion. 
If, on the other hand, the hemor- 
rhage has taken place into the cor- 
tical portion of the kidney and the 
urine has stood for some hours or is 
alkaline, the corpuscles may become 
pale and swollen, their diameter less- 
ened and they may appear as mere 
shadowy circles and as such are 
easily overlooked. Crenation of the 
normal cells may also occur in a 
urine that is deficient in salt. Such 
cells have irregular, star-like processes along their border, but retain 
the yellow tinge of the normal cell. 

Pus. — Pus in quantity is in most cases easily detected by the chemic 
test. The pus cell as seen under the microscope is precisely like the 
white cell seen in a smear preparation of normal blood, but is less easily 
recognized as such in the urine. In the acid urine the pus cells are 
usually larger than the red cells, are colorless, granular and as a rule 
have several nuclei readily distinguished by careful focusing. The 
presence of these nuclei serves to distinguish them positively from the 
red cells. Any doubt upon this point may be readily removed by 
allowing a drop of very dilute solution of acetic acid to run beneath 
the cover-glass, assisting the process, if necessary, by laying the edge 




Fig. 135.-0, b. Various forms of fungi 
and bacteria, c. Pus-cells before and 
after treatment with acetic acid. d. 
Various forms of red blood-cells. 



URINALYSIS — B ACTKRIURI A . 



.343 



of a piece of filter or blotting paper against the opposite edge, ''lie 
acetic acid dissolves the granules and brings out clearly the cell nuclei, 
but unless very dilute, will destroy any hyaline casts that may be present. 
In ammoniacal urine, the pus corpuscles are soon destroyed, becoming 
agglutinated and losing their structural characteristics. 

Varying Significance of Pus in the Urine. — As to the significance 
of pus in the urine, it may be remembered that (a). Pus that comes 
with the -first jet of urine, the remainder being clear, is from the urethra, 
(b). That a moderate amount of pus occurring in an acid urine is usually 
from the renal pelvis; but may be due to tuberculosis of the bladder, 
(c) . Large ■ quantities of greenish pus point to rupture of an abscess* 
into the urinary passages or to a pyelonephrosis. (d). Pus in an ammon- 
iacal urine is usually from the bladder. In all cases the diagnosis must 
depend upon the character of the associated epithelium and the presence 
of casts or specific micro-organisms. 

Spermatozoa are easily recognized by their well known form (see 

fig- 145)- 

Bacteriuria. — Aside from the tubercle bacil- 
lus, many forms of bacteria may be found in the 
un decomposed urine, and their presence may be 
unattended by symptoms or accompanied by a 
variable amount of irritation of the bladder. So, 
also, in fermenting urine one finds both bacteria 
and spores. The spores are highly refractile and 
tend to form chains (see fig. 135). The most im- 
portant bacterium is the tubercle bacillus, only to 
be recognized by such staining methods as are de- 
The ordinary bacterial urine is persistently cloudy. 
has a musty odor, and presents on shaking a swirling appearance, as if 
fine grains of sand were put in motion. 

Epithelium. — In spite of the efforts put forth by microscopists, 
the exact differences existing between the epithelial cells of different portions 
of the urinary tract have been only in part determined. Such variations 
are shown by the plates, but must be learned from the careful study of 
specimens obtained from known cases of cystitis, nephritis, etc., a 
mere description being of slight value. The renal cell as seen in 
the urine is usually small, round and mononuclear. Cells from the 
straight tubules are somewhat larger and have a more irregular shape. 
being sometimes square or polygonal, but all renal cells are mononuclear. 
* Most commonly prostatic. 



Caution. 



Important 
data. 



Note. 




Yeasts, etc 



Fig. 136.— Tub er cle 
bacilli in urine. Observe 
tendency to form groups. 

scribed on page 348. 



Macro- 
scopic tost. 



Limits of 
differen- 
tiation. 



- 



344 



MEDICAL DIAGNOSIS. 



Clinical 

symptoms 

must 

control 

findings. 



Doubtful 
origin. 



Caudate cells arranged in overlapping layers are often described as the 
characteristic cells of the renal pelvis, but as a matter of fact, they repre- 
sent only the superficial layer, and are seen only in early or mild cases 
of pyelitis. The cell from the deeper layer strongly resembles the renal 
cells. Ureteral cells are spindle shaped. Bladder epithelium is generally 
of the well known tesselated or pavement variety, and may be dis- 
tinguished from vaginal epithelium only by the fact that the cells are 
somewhat smaller, never overlap, and occur in a single layer. Vaginal 
epithelium is rather larger; the cells overlap like the shingles on a roof, 
and are likely to occur in masses consisting of several layers. The 
epithelium from the neck of the bladder, prostate, and the calices of the 
kidney pelvis are almost identical. 

Fatty Renal Cells and Compound Granule Cells. — The former 
are much smaller than the latter which are large, round, bulging with 





Fig. 137.— a. Epithelium from 
renal pelvis, b. Vaginal epithe- 
lium. 



Fig. 138.— Bladder epithelium. 
( Various forms.) 



refractile granules and frequently spiculated by fatty crystals. They have 
no exclusive disease relation but may be found in any form of renal lesion 
characterized by fatty casts and in other chronic inflammatory and 
ulcerative lesions of the urinary tract as a whole. Renal cells reflect 
the changes shown by the various types of casts. 

CASTS. — Casts are of two kinds. (1). The true cast, which has its 
origin in an exudate from the tubules of the kidney. (2). The pseudo- 
casts, or cast-like bodies, which may or may not originate in the kidney. 
True Casts. The exact nature and source of the true casts are not posi- 
tively known. Whether they consist of disintegrated and modified 
epithelium, of a morbid secretion of the epithelium, or are simply coagu- 
lated materials exudate from the blood, the fact remains that they appear 



UK IN ALYSIS — C A ST S . 



345 



clinically as casts of the renal tubules, having to a great extent a jorm and 
calibre corresponding to that portion from which they come, and appearing 
hyaline, waxy, fibrinous, granular, fatty, epithelial or bloody, according 
to the nature and extent of the underlying pathologic changes. If we 
assume that their basis is that pathologic change known as hyaline 
degeneration, it becomes very easy to understand most of their modi- 
fications. Such a process would lead ordinarily to the formation of a 
hyaline cast. If the granules of the degenerated cell adhered to or 
became intermixed with the deposit a granular cast would result, and 
this would be finely or coarsely granular, light or dark, according to the 
activity of the pathologic process. Fatty degeneration in the cells 
would be reflected in the fatty cast. Adherent desquamated cells would 
form epithelial cast, adherent blood cells, the blood cast, etc. It is 
reasonable to suppose that the basis is the same for all varieties, and that 




Fig. 139.— Various forms of renal 
cells, including " compound granule 
cells." 



Fig. 140.— a. lilood cast and hyaline 
cast carrying blood-cells, b. Leu- 
cocyte or pus-cast. c. Hyaline cast 
carrying renal cells, d. Epithelial 
casts. 



in the hyaline, waxy, and fibrinous casts we have but slight variations 
in structure, though the conditions attending their presence may be 
quite different and distinct, and their significance definite and impor- 
tant. The hyaline cast is transparent, and shows an apparently homo- 
geneous structure; its size is variable, its cuds rounded, and its sides arc 
nearly parallel. Its shape is best shown in fig. 141. Unless careful 
focusing and proper shading of the light be employed, it will certainly 
escape detection (see fig. 142). Representing, as these hyaline easts 
do, the least degree of pathologic or at least of inflammatory change, 
it becomes at times a difficult question to determine the significance 
and importance of an occasional cast. Some observers report them 
as present in nearly every urine if the centrifuge be employed but such 



Important 
fact. 



A conveni- 
ent hypoth- 
esis. 



>lg!Utl- 

cance of 
by aline 



V, 



346 



MEDICAL DIAGNOSIS. 



True casts 

seldom 
trivial. 



Hyaline 
and 

granular 



Signifi 
cance. 



has not been the author's experience. Occurring alone and unas- 
sociated with albuminuria or other symptoms pointing to diseased 
kidneys, it must be admitted that their significance is less grave than 
would have been assigned them by the older teaching. It is certainly 
true that they may represent transient and hence often negligible 
conditions or localized rather than general renal changes but as a 
persistent constituent of the urinary sediment they still demand serious 
consideration and have lost little of their old significance. It is also a 
much debated question as to whether they are ever found without some 
degree of albuminuria and according to E. S. Wood, the hyaline cast 





Fig. 141. Fig. 142. 

Figures 141 and 142 show the effect of low and high illumination. In figure 141 
hyaline casts are plainly visible, one carrying four renal cells. In figure 142 the casts 
are entirely lost in the flood of light, and only the renal cells appear. 



is always associated with the pale very finely granular cast.* It rapidly 
disintegrates in alkaline urine or in that treated w T ith acetic acid. The 
chief significance of the hyaline and finely granular cast, existing alone, is 
found in their predominance in chronic passive congestion and inter- 
stitial nephritis. 

The Waxy Cast. — This is highly refractile and usually of large size. 
It stands out as clearly upon the field as does the triple phosphate crystal, 
and once seen, is never forgotten. It points to one of three conditions: 
amyloid kidney, advanced chronic parenchymatous nephritis and the 
terminal stage of interstitial nephritis. Ultzmann states that it may be 
Prognostic present in tuberculosis of the kidney. In amyloid kidney, it appears 
value ' earlier than in interstitial nephritis. Indeed, in the latter it marks the 

beginning of the end and cases of contracted kidney in which it is found 

* This corresponds to the author's own observations as applying to ordi- 
nary clinical work and to true casts and seems to have a logical pathologic 
foundation. 



URINALYSIS — CASTS. 



347 



Color 
important. 



will usually terminate fatally within one year. The Fibrinous Cast. 

— This misnamed cylinder resembles the waxy cast save in color. It is 

always yellow or even brown, deriving its color from blood pigment, 

and, as might be expected, points to an active or subsiding inflammation, 

ordinarily to acute Bright's disease. The Blood Cast.— This points JggSJgJJ 

to acute inflammation, as does the brown (dark) granular cast* The 

coarse granular cast is usually associated with fibrinous or with waxy 

casts. The fatty cast is most frequently seen in convalescent cases oj 

acute nephritis, or in chronic parenchymatous nephritis. Epithelial 

casts occur only in acute or subacute inflammation, in acute Bright's 




Fig. 143.— Granular cast light and 
dark, coarse and finely granular. 




Fig. 144. — a. Waxy casts, 
or fat-bearing casts. 



*. Fatty 



disease, or the subacute exacerbation oj a chronic parenchymatous nephritis- 
Many casts carry here and there an epithelial cell, yet cannot properly 
be called epithelial casts. Pus casts are found in suppurative disease 
of the kidney or in pyelitis extending to the straight tubules and fre- 
quently require treatment with dilute acetic acid to distinguish them 
from epithelial casts. 

Significance and Association of Casts. — Hyaline and Finely 
Granular Casts indicate: — (a). Interstitial nephritis, (b). Amyloid 
kidney, (c). Chronic congestion of kidney. Waxy Casts indicate: — 
(a). Terminal stage of chronic interstitial nephritis, (b). Advanced 
parenchymatous nephritis, (c). Amyloid kidney. In Acute and Sub- 
acute Nephritis one finds (a). Fibrinous, (b). Blood, (c). Epithelial, 
(d). Hyaline and (e). Dark granular casts. /;/ convalescence from acute 
nephritis one finds fatty, dark granular, epithelial and hyaline easts. 

* If, as is usually the case, the cast carries washed oul cells (abnormal 
blood) it indicates slow effusion of blood or a high origin — if normal blood, 
more abundant hemorrhage or an origin in the straight tubules or pyramids. 



348 



MEDICAL DIAGNOSIS. 



In uncomplicated chronic parenchymatous nephritis one finds, fatty, 
hyaline and finely granular casts and with any decided disturbance 
epithelial casts. 

Sources of Error in Searching for Casts. — Cast-like Forms. The 
amorphous urates are frequently grouped in cast-like forms and similar 
accumulations of bacteria and other sedimentary substances may per- 
plex the tyro. They will seldom or never deceive the trained eye as they 
lack the definite boundary -line of the genuine cast. Urates, more- 
over, are promptly dissolved by heating the preparation. More 
deceptive still are the cylindroids. They are usually longer and 
more band-like than the hyaline cast, and more likely to be convoluted 
or twisted; usually they take the form 
known as mucous cylindroids which 
occur in many non -albuminous urines 
and cannot be mistaken for true casts 
as they appear flattened and ribbon 



Accidental 
casts. 



Mislead- 
ing forms. 



Mucous 
cylin- 
droids. 



Demand 

typical 

forms. 



Cylindroid 
storms. 



Pyuria 

sometimes 

absent. 




Fig. I4S-— Spermatozoa and associ- 
ated substances in urinary deposit. 
a, a, a, a. Spermatozoa, c, c. Sper- 
matozoa, tail out of focus, d, d, d. 
Amyloid corpuscles. e. Prostatic 
cast. g. Crystals. h. Lecithin- 
granule cells. k,k,k. Epithelium. 



like, often with frayed ends and faint 
longitudinal striation. The author be- 
lieves that fewer casts would be re- 
ported in otherwise normal urines if 

I the observer regarded all doubtful 
forms as disproven until he could find 
in the same urine a definite cast of the 

, ordinary size and form and with both 
ends rounded. If of renal origin the 
unusual will certainly be accompanied 
by the common form. In a case recently observed periods of hypo- 
chondria were accompanied by showers of spurious casts without the 
slightest change in the chemical constitution of the urine. 

Prostatic Plugs. — These may closely resemble the large hyaline 
or fibrinous cast but usually carry or are associated with sperma- 
tozoa, and are associated with evidence of prostatic irritation or 
inflammation. 

The Examination of the Urine for Tubercle Bacilli. — Tubercle 
bacilli may be found in urines that are in every other respect almost 
normal. If such a condition be suspected, the urine must be subjected 
to prolonged treatment in the centrifugal machine. The sediment is 
then examined precisely as in the case of the sputum (see page 114), 
save that a small quantity of egg albumin is added to the specimen 
before placing it on the cover-slip. 



. 



URINALYSIS — GONOCOCCUS— TYPHOID. 



349 



Simple 
method. 



Shreds. 



THE GONOCOCCUS.— As indicating the infectivity of any per- 
sistent secretion after urethritis the presence of gonococci is important. 

Method.— The usual smear is made, dried in the air and fixed, and 
indeed may be made by the patient if no discharge is present save in 
the early morning or at irregular times. Ordinarily the Jenner's stain 
or the alkaline methylene blue are sufficient. In any case of unusual 
importance it may be necessary to use cultural methods as it is claimed 
that the micrococcus catarrhalis may cause confusion. The so-called 
urethral thread, though common after gonorrheal infection, indicates 
no more nor less than chronic congestion of the deep urethra. 

EHRLICH'S TYPHOID DIAZO-REACTION.— The test was 
introduced by Ehrlich in 1882, and, after meeting much opposition and 
criticism born of misunderstanding and misapplication, has at last been 
accepted at its true value in most of the important clinics. 

Solutions Required. — Solution A. Hydrochloric acid, 50; distilled 
water, 1000; sulphanilic acid, q.s.ad sat. (should be thoroughly satur- 
ated). Solution B. Sodium nitrite (not nitrate). 0.5 per cent (£ of 
1%), solution in distilled water. Solution C. (Test Solution.) One 
hundred parts of A plus one part of B. 

The original test solution of Ehrlich was made by adding to 40 parts 
of Solution A 1 part of Solution B. This the author has slightly modi- 
fied by using 100 parts of A to 1 of B, .with the effect of eliminating 
many disturbing factors and doubtful reactions. Dr. C. E. Simon 
suggested the ring method of testing described below. To apply the 
test, take equal parts of C and the urine. Shake thoroughly and add 
aqua ammonia in excess, allowing it to run gently down the tube so as to 1 Techr 
overlay the mixture below. If the reaction be present, a deep-red band 
appears at the line where the ammonia meets the mixture; when 
shaken, it yields a pink or rose-colored foam and after standing several 
hours, a green precipitate forms. The following rules must be care- 
fully observed: — (1). Use fresh urine. (2). See that the reaction is 
acid and the urine filtered. (3). Use a fresh test-solution. (4). Keep 
the sodium nitrite solution in a black bottle, and in a cool place and renew 
it frequently. The sulphanilic solution keeps indefinitely. (5). Hold 
the tube near, but not against, a white background, the source oj light being 
behind the observer. Artificial light should not be used. (6). Accept 
no color but a distinct red, and regard no reaction as a true one in which 
the solution when shaken does not yield a pink foam. Pseudo-reactions 
occur in which the band is of the proper color, but the foam is yellow or 
brown. The most absurd errors have arisen from a failure to observe 



Author s 
modifica- 
tion. 



Important 

rules. 



Absurd 



J 



35° 



MEDICAL DIAGNOSIS. 



Sources 
of error. 



Real value 
great. 



Pseudo- 
reactions. 



Cerebral 
symptoms. 



the exact technique here outlined and some excellent men have used 
sodium nitrate, weak ammonia, or even omitted the addition of ammonia 
altogether, and naturally failed to get consistent results. Others have 
admitted yellow and orange reactions, or have even used a 5% solution 
of sodium nitrite. The test is not pathognomonic, as was originally 
maintained by Ehrlich, but is constant in all severe forms of typhoid, 
appearing sometimes as early as the fourth or fifth day, though more 
generally at the end of the first week or ten days, and persisting until the 
fever begins to decline. If the test be applied according to the author's 
method the true reaction is absent in malaria, appendicitis, pneumonia 
and the earlier stages, at least, of acute miliary tuberculosis, occurring 
only in the author's experience in some of the exanthemata, in certain 
cases of advanced malignant disease, late in miliary tuberculosis and in 
febrile cases associated with septic absorption. Pseudo-reactions are 
found in a considerable number of diseases and the inclusion of yellow 
and orange reactions has discredited a good test. It is of great value, 
as a negative sign, for it is the author's firm belief, that it will be found 
present in all severe cases of typhoid, and that its persistent absence in 
any such case quite certainly negatives the diagnosis of typhoid* 

UREMIA. — Any form of Bright' s disease may be associated with 
symptoms grouped under the head of "uraemia." The exact cause of 
this condition is unknown but its occurrence depends upon the reten- 
tion of certain excretion products distinctly toxic in their nature. It is a 
well known fact, that no living organism can resist the poisonous effect 
of its own waste products, and in the elimination of these substances the 
kidney plays the chief part. The symptoms of uraemia are made mani- 
fest chiefly through the nervous system, although the gastro-intestinal 
and respiratory tracts are almost invariably involved. 

Nervous Symptoms of Uraemia. — Almost every disease of the nervous 
system may be simulated by urcemia, but the cerebral symptoms are the 
most interesting and important. Headache, drowsiness, stupor or coma 
may be found individually or as transition stages. There may be slight 
twitching or the more terrible convulsive seizures closely simulating 
epilepsy, and violent outbreaks of acute mania, profound melancholia, 
or the so-called delusional insanity of Bright's disease may easily lead 
to serious error in diagnosis or even to the committal of such patients 



* Recently Unverricht, in quoting Michaelis an enthusiastic advocate, has 
raised anew the old question of color and demands a more definite reaction. 
A deep red band and a pink foam may and should be demanded by every 
clinician before the individual reaction is accepted. 



— 



GASTROINTESTINAL SYMPTOMS. 



351 



to an asylum for the insane.* Various disturbances of general sensation 
may be encountered such as itching, anaesthesia, hyperesthesia, formi- 
cation and abnormal response to heat and cold. Vertigo is often a 
prominent feature and is usually associated with periods of marked 
circulatory depression, diminution of total solids or the predominance 
of the dyspeptic symptoms, often so prominent a feature in this disease. 
The most remarkable symptoms of uraemia are those extraordinary 
attacks of paraplegia or hemiplegia simulating true apoplexy, and the 
disturbance of the special senses resulting in uraemic tinnitus aurium, 
deafness or sudden temporary blindness (uraemic amaurosis). f Various 
more serious eye symptoms may co-exist with uraemia and the diagnosis 
of chronic interstitial nephritis is often first made by the oculist, who dis- 
covers evidence of a neuro-retinitis of the albuminuric type. Uraemic 
amaurosis usually lasts but one or two days and ordinarily follows some 
profound manifestation of uraemia, such as coma or convulsions. Cases 
presenting marked symptoms of actual albuminuric neuro-retinitis seldom 
live longer than one year. 

Respiratory Symptoms. — Cases of chronic nephritis are often 
peculiarly subject to inflammation of the pulmonary structures, but 
aside from these we have curious disturbances of respiratory rhythm 
and uraemic dyspnoea may be continuous, paroxysmal, alternating, 
or Cheync-Stokes. The paroxysmal type is often mistaken for true 
asthma, the mode and time of onset being identical. Continuous dys- 
pnoea of uraemic origin is not uncommon, and medical literature fur- 
nishes many evidences of an ambulatory Cheyne-Stokes type.% 

Gastro-intestinal Symptoms.— r/zese so closely simulate various 
independent diseases as to render diagnosis impossible, except by reference 
to the urine and particularly the estimation of urinary solids. As pre- 

* A remarkable case in the author's practice showed the existence of a 
uraemic delusion, single but fixed and dominant, which lasted about three 
years, during which period the patient was converted from the warmest 
friendship to the most bitter enmity, returning suddenly to his first status 
at the end of the period. In this case the albuminuria was intermittent 
with frequent periods of marked deficiency of excretion, as indicated by 
estimation of the urinary solids. Several physicians pronounced the man 
wholly free from disease, because of the absence of albumin from individual 
specimens of urine. 

t Amaurosis, i. e., blindness usually temporary and removable and with- 
out apparent lesion may also be encountered in hysteria, migraine, acute 
Severe hemorrhages, tobacco and cocaine habituation and diabetes. 

|: In one ease of interstitial nephritis in the author's practice, typical 
Cheyne-Stokes breathing was present at night for over three years before 
the patient's death and was occasionally present in the daytime. 



Sensory. 



Paralyses. 



Eye 

symptoms. 



Dyspnoea. 



Urinary 

solids. 



352 



MEDICAL DIAGNOSIS. 



Uraemia 

sine 

nephritis. 



Note. 



Essential 
data. 



Uraemia 



Aceto- 
naemia 



viously stated, these uraemic symptoms may be evident in any case of 
nephritis; the author believes that they may also be present in minor 
degrees at least without actual nephritis, if the functional activity or 
capacity of the kidney is temporarily deranged or lost. Nevertheless 
its most extreme manifestations are encountered in chronic interstitial 
nephritis, or even more commonly in chronic diffuse nephritis with 
exudation* The onset of uraemia is almost invariably associated with 
lessened quantity oj urine and a sharp reduction in total solids and urea. 

Uraemic Coma. — This may closely simulate apoplexy, but is rarely 
so sudden in onset and is more generally preceded by convulsions, a 
history of which should be carefully sought. Such cases are the bete 
noir of the hospital physician on account of the difficulties in differen- 
tiation. The following points should be noted: — (a). An examina- 
tion oj the urine obtained by catheterization is of the first importance, as 
it may yield evidence of an active or chronic nephritis, or show a 
marked reduction in solids, (b). A history of antecedent convulsions 
or convulsive movements may be obtainable, (c). The pupils yield 
no certain signs, (d). Paralyses are rare though there may be mus- 
cular twitching and rigidity of the extremities if severe convulsions 
have occurred, (e). The temperature may be elevated, but usually 
it is normal or subnormal, (f). Ophthalmoscopic examination may 
show retinal changes, (g). The general aspect of the patient may 
clearly indicate the existence of renal disease, (h). Little dependence 
can be placed upon the odor of the breath as indicating renal toxaemia. 
Uraemic odor is sweet, nauseating, chloroform-like and may per- 
vade a whole apartment, but is found in connection with profound 
toxaemia, resulting from cardiac failure, advanced hepatic disease, renal 
disease, and sometimes in connection with malignant growths. It lacks 
the peculiar quality of the breath as encountered in diabetic coma in 
which there is an actual fruity fragrance of the most penetrating quality. 

CRYOSCOPY. — The introduction of endoscopy by Koranyi represents 
an effort to secure more exact information especially concerning renal 
activity and efficiency by determining the freezing point of the blood 
and urine. The greater the molecular concentration of a water} 7 fluid the 
lower is its freezing point and assuming that the average freezing point 
of normal blood ranges from — 0.56 to — 0.58 C. and that of the urine 

* A case under the author's observation for five years showed during that 
period nearly every symptom to which reference has been made in a pre- 
ceding page, and amongst these were attacks closely simulating hysteria, 
but promptly removed by radical therapeutic measures, while no less than 
three times before death the patient was found in deep uraemic coma. 



DISEASES OF THE KIDNEY — CRYOSCOPE. 



353 



between — 0.9 and — 2 C. it is evident that the lower freezing point 
on the part of the blood indicates a greater concentration and that a 
higher figure for the urine indicates a lessened molecular content. It 
further appears that a test of the urine taken by catheterization from 
each kidney might determine the relative functional activity of those 
organs and that the procedure would prove a guide to the surgeon in 
nephrectomy as well as to the physician in connection with the so-called 
uraemic states and renal inefficiency. 

THE CRYOSCOPE— The Fontaine instrument* consists of a freez- 
ing chamber containing a properly supported central tube within which yet 
another tube may be so adjusted as to leave an air chamber between them. 
Within the latter is a delicate thermometer registering from — 3 to 3 C. 
in graduations of 1-200 and this is encircled by a spiral stirrer, neither 
touching the sides of the innermost tube. Method. — The large tube 
being in position the freezing chamber is filled with cracked ice and rock 
salt in alternate layers terminating in an upper layer of salt an inch in 
depth; 10 c.c. of the blood or urine have in the meantime been placed 
within the inner test-tube and put in or upon ice to cool during the prep- 
aration of the freezing mixture (5 to 10 minutes). The small tube is 
then placed within the large one and fitted with the thermometer, care 
being taken that the latter's bulb is immersed but that the instrument 
is at no point in contact with the wall of the inner tube. After about 5 
minutes of continued stirring a slow fall followed by a rapid drop occurs 
to about — 2 C. at which point the reading is stationary for some minutes 
and then rises to the true freezing point, again falling to the temperature 
of the freezing mixture. The reading should be made with the eyes 
at the level of the mercury column. It is assumed that a freezing point 
of — o.6° C. or lower for blood and i° C. or higher for urine indicates a 
sufficient degree of renal inefficiency to forbid surgical interference. 
As might be expected this method has its enthusiastic advocates and no 
less strenuous opponents. Space will not permit a full discussion of 
the strength or weakness of the procedure, but a just idea may be ob- 
tained by reading Sahli's admirable, critical discussion,! and the book 
of its enthusiastic advocates, Casper and Richter.J Such careful ob- 
servers and enthusiastic workers as DaCosta and Cabot are unwilling 
to subscribe to the claims made for it. and to the author it appears abso- 

* Madi- by ('■■ Fontaine, i(> Rue Monsieur la Prince, Paris, or tin- highly 
recommended modification of tin- A. 11. Thomas Co., Philadelphia. 



I " Diagnostic Methods." 
I " Functional Diagnosis 

23 



Kid! 



- 



w 



354 



MEDICAL DIAGNOSIS. 



Simple 
methods. 



Clinically 
adequate. 



Total 
nitrogen. 



lutely impracticable as a working clinical procedure, and one so subject 
to serious error from slight causes and to wide variation in apparently 
normal cases as to cast grave doubt upon the findings obtained. 

RENAL INEFFICIENCY.— (Renal inadequacy.) Aside from cry- 
oscopy many efforts have been made to determine the functional efficiency 
of the kidneys, especially with relation to actual or suspected medical or 
surgical diseases of those organs, but so far no method has been evolved 
which is free from serious objection and at times gross errors. Indeed 
it would seem at present that the excretion of total solids as represented 
by the specific gravity figures, and the special procedure for the determin- 
ation of urea and the chlorides offer the best means available for the 
busy practitioner. So far as the personal experience of the author is 
concerned these have proven adequate and seldom misleading in medical 
work and to them no objection can be urged which cannot be met by 
an equal or greater counter objection to the proposed substitutes. The 
estimation of total nitrogen can hardly be adapted to the examination 
of specimens obtained by ureteral catheterization which represent small 
separate specimens, and furthermore involves an absolute knowledge of 
the ingesta, of excretion through channels other than the kidney, a com- 
plicated chemical estimation, and repeated tests covering a considerable 
period; all of which requirements place it entirely outside the possibilities 
of clinical work under ordinary conditions. 

Methylene Blue. — Achard and Castaigne some years ago recommen- 
ded and used methylene blue for the determination of the functional 
activity of the kidneys, using intramuscular injections and noting the 
time elapsing between its administration and the subsequent discolor- 
ation of the urine as well as the approximate amount of the coloring 
matter recovered. It has been found, however, that the test is of little 
value as a measure of renal insufficiency, the elimination being unmod- 
ified in parenchymatous and amyloid nephritis, thus proving that 
important renal constituents do not act as does the dye. 

The Relative Toxicity of Urines.— Bouchard's method of determin- 
ing the relative toxicity by injecting urine into guinea pigs is so full of 
error variations as to be entitled to little respect, nor is it in any way 
adapted to ordinary clinical work. 

The Phloridzin Test. — The objections to phloridzin as a test sub- 
stance are much the same as against methylene blue, though it is prob- 
able that an estimation of the glycosuria following the administration 
of this drug furnishes an approximate idea of the functional capacity of 
the kidney. 



Obsolete. 



Of some 
value. 



DISEASES OF THE KIDNEY— CONGESTION. 



355 



Comment. — It would seem to the author that in view of the fact that 
no unobjectionable or infallible method has been evolved, one is justified 
in falling back upon those that are simplest and that furnish clinical 
results of decided significance. In other words, until better methods of 
an accurate and decisive nature and greater simplicity are evolved, 
the practitioner is justified in depending upon the rough estimation of 
total solids and the approximate determination of nitrogen by the urea con- 
tent. As a matter of fact in those conditions associated with uraemic 
crises there is seldom any doubt as to the temporary or permanent 
disability of the kidneys, nor, as before slated is this confined ex- 
clusively to renal disease, though the urine gives the best indication. 
Careful observation of a number of cases presenting the symptoms of a 
modified uroemia but with apparently normal kidneys, and of precisely 
similar cases with known renal disease has convinced him that the decided 
reduction in urea, preceding, and associated with the onset in each and 
every one of these cases, together with the disappearance of all symptoms 
under treatment directed to a restoration of renal activity strongly suggests 
the possibility of a purely functional inefficiency, associated with reten- 
tion symptomatically indistinguishable from the uraemia of B right's 
disease. Furthermore in all these cases not only was the specific gravity 
decreased, but urea was in every case less than half the normal, and, 
although the diet was uniform, cessation of symptoms and the rise in 
the urea percentage and specific gravity were invariably coincident. 

CHRONIC PASSIVE CONGESTION OF THE KIDNEY.— 
This is always venous and secondary to diseases of the heart, lungs or 
liver, or to pressure on renal veins by abdominal tumors including the 
pregnant uterus and ascitic fluid. Morbid Anatomy. — The kidneys 
ordinarily show a simple venous hyperaemia. 

Symptoms. — There are no symptoms of importance save those refer- 
able to the primary lesions and the urinary findings. Urine. — The 
total amount is diminished, total solids approximately or actually normal. 
Reaction. — Acid. Color: — Distinctly high save in diseases characterized 
by marked impairment of nutrition. Albumin is present only as a trace 
except in pregnancy when large amounts may be found. Microscopic 
Findings. — An occasional hyaline or finely granular cast, together with 
a few renal cells. 

The Kidney of Pregnancy. Even though the condition may be one 
of simple pressure hyperaemia, the amount of albumin is likely to be 
larger than in other instances of chronic passive congestion, and it must 
not be forgotten that active hyperaemia or acute or chronic inflammatory 



Secondary 
and venous. 



1 



356 



MEDICAL DIAGNOSIS. 



Caution. 



Total 
solids. 



Mild 

vs. 
Severe con- 
gestion. 



Faulty 
classifica- 
tion. 



diseases of the kidneys may accompany this state. In this connection 
it is of the utmost importance that specimens of urine be submitted fre- 
quently to the attending physician and that these represent the 24 hours 
urine, and not the individual hap-hazard specimen. Furthermore, 
the essential feature of the examination, as indicating danger to the 
patient, lies in the estimation of urinary solids, particularly of urea. 
This point is often overlooked by the practitioner, who may mistakenly 
regard the amount of albumin as the important feature. 

ACUTE CONGESTION OF THE KIDNEY AND ACUTE 
NEPHRITIS. — These conditions should be considered together, inas- 
much as the causes operating to produce them are essentially identical, 
and further, because no line can be drawn between actual acute neph- 
ritis and severe congestion, save that based upon the duration of 
symptoms. Mild congestion of the kidney of the arterial type occurs 
under many conditions of slight potency, and is the antithesis of the 
severer types, the amount of urine being increased, but a small trace 
of albumin being present, and the urinary solids being actually or ap- 
proximately normal. 

Etiologic Factors. — Any acute congestion and inflammmation. Irri- 
tating Drugs. — Among these are copaiba, cubebs, sandal-wood oil, 
turpentine, cantharides, carbolic acid, phenol compounds generally, 
arsenic, lead and mercury. These cause trouble only when ingested in 
excessive doses, or for too long a period. Insoluble Urinary Constit- 
uents. — Uric acid, calcium oxalate, cystin, acid urates and phos- 
phates are the chief factors. Toxines. — These may be divided into 
three groups: — (1). Those associated with acute febrile infections and 
especially with the exanthemata and certain virulent tropical diseases 
of which yellow fever is the chief. (2). Suppuration with septic 
absorption. (3). Chronic diseases such as syphilis, gout, malaria, 
pulmonary tuberculosis, diabetes mellitus and certain of the anaemias. 
Nervous Influences. — It has been customary to place under this head 
the nephritis attending such conditions as acute mania, delirium 
tremens and the so-called ascending or reflex congestions connected 
with diseases of the bladder, seminal vesicles, urethra and the prostate. 
It is probable that this is incorrect. In many of the cases of acute mania 
a nephritis is the antecedent factor of which mania may be but a symptom. 
In delirium tremens the habits of the individual, the likelihood of pre- 
existing disease, the exposure and exhaustion attending a debauch 
leave little room for the older classification. In the case of the so-called 
reflex or ascending congestion, save in the rarest instances, we are prob 



— - 



DISEASES OF THE KIDNEY — ACUTE CONGESTION. 



357 



ably dealing with an extension of infection. General Causes. — Sexual 
excesses, the excretion of large quantities of bile, and extreme concen- 
tration of the urine seem adequate to produce mild congestion. Fatigue, 
mental or physical, particularly when combined with exposure to cold 
or wet, would seem to be the most active exciting causes. 

Morbid Anatomy. — The complex description and the varying 
terminology used by different writers and investigators lead to much 
confusion on the part of the student when he approaches the sub- 
ject of renal pathology. The really essential factor should be clearly 
held in mind. All renal lesions, acute or chronic, fall under three 
heads: — (i). Those in which glomerular changes predominate. (2). 
Those in which the interstitial changes are most prominent. (3). 
Those in which all structures are affected without predominance of any 
one group. It must always be borne in mind that the finer classification 
and sub-divisions are of pathologic interest only, and that in any inflam- 
mation of the kidney, acute or chronic, one is likely to find all structures 
involved, so that it becomes simply a question of relative predominance. 
In an acute nephritis or severe acute congestion of the kidney, either 
glomerular, tubular or interstitial changes may be primary or predomi- 
nant. With the exception of acute non-suppurative interstitial neph- 
ritis, the three fundamental structures are involved, and in any event, no 
clinical distinction can be made. We ordinarily find cloudy swelling, 
desquamation, and hyaline, dropsical and fatty degeneration or complete 
necrosis of the epithelium of the tubules, which are crowded with in- 
flammatory detritus. We are likely to find acute intra-capillary glomeru- 
litis, the capillaries being filled with cells and thrombi, and the epithelium 
of the tuft and capsule being involved. The latter is crowded with 
blood cells and leucocytes, and it will be readily seen that interference 
with renal circulation and nutrition, and hence with the urinary volume 
is inevitable, and further that the loss of integrity on the part of the 
filtration apparatus must necessarily lead to the escape of albumen. 
In rare instances a portion only of the kidney may be involved, or the 
process may be unilateral. The gross appearance of the kidney varies 
somewhat: it is ordinarily swollen and red, dripping blood on section, 
having a sueeulent feel, with an easily stripped capsule. More rarely 
it may be pale and mottled, exuding on section a milky fluid (acute non- 
suppurative interstitial nephritis). The glomeruli are usually red and 
prominent, but may be pale ami indistinct. 

Symptoms.- The symptoms vary in severity with the type of the 
disease. An acute congestion may give few outward signs, and even an 



Chief 

cause. 



Essential 
factors. 



Clinical 
aspect. 



Microscop- 
ic findings. 



Macroscop- 
ic findings. 






- 



w 



358 



MEDICAL DIAGNOSIS. 



Pulse 
tension. 



Variable 
onset. 



Early 
edema. 



acute inflammation may first announce itself by uraemic convulsions or 
coma. One of the best guides in the case of nephritis complicating 
other diseases is found in the pulse tension, which is almost invariably 
increased in the presence of either acute renal congestion or inflammation. 

General Symptoms. — The onset may be sudden and frank, with 
chill and sharp temperature rise, or it may be gradual and insidious. 
There is usually some pain or heaviness in the loins and increased fre- 
quency of micturition, the pulse tension increases, and nausea, vomiting, 
headache and thirst may be present. The severity of the initial symp- 
toms bears no definite relation to the type of the disease, save that those 
of simple acute congestion are ordinarily milder and more evanescent. 
In some instances, the first thing noted is pufnness under the eye, the 
development of general edema, or even uraemic convulsions or coma. 
As a rule, however, these last symptoms occur only after several days of 
illness. Fever is ordinarily present, but is seldom high, and is often 
masked by that of a primary disease. In yellow fever the renal symp- 
toms are often most striking and prominent. The edema of acute 
nephritis is oftentimes extreme, is likely to appear first in the eye-lids and 
tissues of the face and the skin is white and "pasty." In the extremi- 
ties the swelling is comparatively firm, though pitting deeply on pressure, 
and because of the blue veining on the dead white background, is often 
termed "marble-like" edema. There is a special tendency to secondary 
complicating symptoms, especially affecting the serous membrane and 
the myocardium, and to attacks of edema of the glottis which may 
cause sudden death by suffocation. 

Special Precautions. — At least once daily the attending physician 
should by careful examination exclude endocarditis, myocarditis, 
pericarditis and pleurisy, with or without effusion, the condition last 
named often coming on rapidly and insidiously. Edema of the glottis 
usually demands immediate recourse to the most radical measures, 
emergency tracheotomy being the one usually found necessary. A 
jew moments of indecision and delay has more than once caused death. 

Urinary Findings. — It should be understood that the urinary find- 
ings in acute congestion vary with its severity but tend to assume, pari 
passu, identical characteristics. Severe acute congestion can be differ- 
entiated from acute nephritis only by its shorter duration, but the mild- 
ness of the slighter grades makes their recognition easy. The student 
should refresh his memory regarding the subject of albuminuria and 
the findings and significance of casts (pp. 324, 344) before taking up 
the following section. The findings fall naturally under three heads: 



Complica- 
tions. 



Glottic 
edema. 



DISEASES OF THE KIDNEY — NEPHRITIS. 



359 



First Stage. — (5 to 10 days.) Quantity jor 24 hours 100-400 c.c. 
Color: — dark, smoky or black. Specific Gravity. High or low, albumin 
may raise it to 1030; invariably low if albumin is removed. Reaction. 
Acid, or from large quantities of blood, slightly alkaline. Solids. 
Absolutely diminished, urea greatly diminished, chlorides may be ab- 
sent if dropsy be extreme. Sediment. Abundant dark sediment. 
Casts abundant, dark granular, epithelial, fibrinous and blood casts 
with a few hyaline and fine granular. Casts carrying leucocytes, 
caudate pelvic cells, and round cells from calices. Albumin. £-1% 
according to degree of tubal involvement. Red blood cells abundant, 
leucocytes, brown granular epithelial cells. 

Second Stage. — (5 to 10 days or more.) Amount 600-1500 c.c. 
Color, dark, smoky. Specific Gravity 1015-1020. Reaction. Acid. 
Solids. Still diminished. Albumin $-£%, diminishing pari passu with 
urine increase. Sediment. Profuse and dark; fatty changes now evi- 
dent as fatty casts and renal cells and compound granule cells. The 
amount of fat indicates improvement and measures the severity of 
primary attack. 

Third Stage. — Convalescence. Edema if present has now disap- 
peared. Quantity 1500-4000 c.c. Tendency to polyuria, may last 
weeks. Color. Pale or slightly smoky. Reaction. Acid. Specific Grav- 
ity. 1 006-1020. Solids. Normal or slightly increased by absorption 
of exudate. Albumin. Trace to $■ of 1%. Sediment. Scant, light 
color, abnormal blood cells (rings) (ghosts), occasional hyaline and 
granular (dark and light) casts, possibly an epithelial fatty or fibrinous 
cast. A few renal cells. Casts and renal cells may carry fat droplets 
or abnormal blood cells. As improvement continues the evidence of 
acute and regenerative changes disappears and urine is at last normal. 
Any chronic renal disease may show acute or subacute exacerbations. 

Prognosis. — Less common and less fatal in dry than in damp 
climates. Children give large mortality, 30%, especially scarlatina 
cases. Low tension, uraemia, serous effusion arc bad. Failure to 
improve after 10 days means liability to chronic disease. Persistent 
profound anaemia is a threatening sign. Recovery may take place even 
after one or two years. Relapse and multiple relapses frequent. 

CHRONIC PARENCHYMATOUS NEPHRITIS. -Etiology.— 
An antecedent acute nephritis, prolonged exposure to wet and cold 
under conditions of fatigue, chronic malarial infection, syphilis, alcohol- 
ism, chronic suppuration are the common factors, Morbid Anatomy: 

Glomerular, tubular and interstitial changes are present, the first pre- 



3 6 ° 



MEDICAL DIAGNOSIS. 



Usually 
pro- 
nounced. 



Frank. 



Caution. 



g a special tendency to headache, 
nausea, vomiting and diarrhoea. 



dominating. The kidney is large, its capsule may be adherent, but 
usually strips easily from the pale and mottled kidney surface; section 
shows increased resistance and a swollen white cortex with curious areas 
of opacity. Microscopic Findings. There are obliterative hyaline 
degenerative changes in the vessels of the glomeruli, involving both the 
cells and the vessel walls and the tufts show swelling and nuclear pro- 
liferation. There is a tendency to connective tissue ingrowth and 
proliferation and desquamation of the capsular epithelium. The 
tubules show degeneration, desquamation and necrosis of their epithe- 
lium and edema and connective tissue infiltration of the intertubal 
tissues. 

Symptoms. — The general symptoms are usually frank, pronounced 
anaemia and edema being prominent; the various uraemic phenomena 
are common and recurrent, there bein 
dyspepsia, intractable neuralgias 
Pleurisy and pericarditis are common, ulceration of the colon occa- 
sionally occurs, and there is a constant tendency to increase of edema 
and to general anasarca. The circulatory changes are pronounced, the 
pulse tension is high, the second aortic and apical first sound markedly 
accentuated and the left ventricle hypertrophied. 

Urinary Findings. — It is customary to separate the urinary symp- 
toms into those of the active, as compared with the inactive stage. 
It will be noted that the essential symptoms are the same under both con- 
ditions, i.e., a decided albuminuria, the presence of fatty casts, and 
marked diminution of the urinary solids. The disease is especially 
liable to subacute exacerbations, giving to the urinary findings a resem- 
blance to an acute nephritis of the early stage of convalescence. 

Active Stage. — Amount. 200-800 c.c. Color. High or pale, yel- 
low or greenish, often smoky from exacerbation. Reaction. Acid. 
Specific Gravity. High from albumin, 1026-1035, but actually low. 
Solids. Greatly diminished, especially chlorides and urea as in all 
dropsical cases of renal disease. Albumin. Tremendous, tube may 
boil solid. 3-2% (5% has been reported, average 1%). Sediment. 
Always considerable, hyaline, granular, fatty casts, fatty epithelium 
and compound granule cells. Epithelial casts indicate superadded or 
recent or subacute trouble, free fatty cells, fatty crystals, cholesterin in 
late stages, ditto waxy casts, often red blood cells. Inactive Stage. 
— Quantity 800-1200. Color. Pale or greenish. Reaction. Acid or 
neutral. Specific Gravity. 1010-1015. Solids. Greatly diminished. 
Albumin. Large. \-\. Sediment. Practically as in active stage. 



DISEASES OF THE KIDNEY — NEPHRITIS. 



361 



Prognosis. — If the disease is strongly intrenched and not merely 
a protracted case of acute Bright's disease, its victims rarely recover, 
but die in a few years of pulmonary edema, general anasarca or uraemia, 
the average duration of the disease being a little over two years. 

THE SMALL WHITE KIDNEY.— This rare condition is sup- 
posed to represent an advanced stage of an unusually prolonged 
chronic parenchymatous nephritis with ultimate predominance of the 
interstitial elements. 

Morbid Anatomy. — The kidney is small and yellow, because of the 
immense predominance of fatty change, connective tissue hyperplasia 
is marked, the capsule being thick and adherent, and the kidney surface 
under it rough and granular; on section there is increased resistance; 
the cortex is thin, pale, yellow, and covered with yellowish, white spots. 
Microscopic Findings. The interstitial changes are marked, there is 
arterial thickening, and the glomerular and tubule structures are 
degenerated and largely destroyed. 

General Symptoms. — These are essentially the same as in paren- 
chymatous nephritis, changes in the heart and blood vessels being more 
pronounced. Urinary Findings. — Quantity. Normal or slightly in- 
creased. Color. Pale. Reaction. Acid or neutral. Specific Gravity. 
1004-1010. Total Solids. Greatly diminished. Albumin. \ of 1% or 
less. Sediment. Same as in chronic parenchymatous nephritis, save 
that casts are less abundant, and that waxy casts are found in unusual 
numbers. 

CHRONIC INTERSTITIAL NEPHRITIS.- ("Gouty" kidney, 
"contracted" kidney, "cirrhotic," "granular," "sclerotic" or "small 
red" kidney, "chronic diffuse" nephritis, etc.) 

Morbid Anatomy. — The kidneys are usually small, an instance 
having been reported in which their combined weight was i\ oz. The 
capsule is thickened and adheres to the dark red, nodular, granular 
surface, and section shows an increase in resistance. The arteries are 
prominent, the cortex very thin, the pyramids wasted and the pelvic 
fat increased. Microscopical Changes. These are essentially those of 
connective tissue overgrowth, with atrophy and degeneration of both 
glomerular and tubular structures. Many of the glomeruli and tubules 
are entirely destroyed. It is hardly worth while to distinguish an ar- 
teriosclerotic kidney from a true interstitial nephritis. In the former, 
the change is primarily arterial, and the connective tissue changes are 
less diffuse, but in both, degeneration, atrophy, and destruction of the 
secreting structure is the essential feature. 



Synonyms. 



Arterio- 
sclerotic 
form. 



j 



362 



MEDICAL DIAGNOSIS. 



Heredity. 



Insidious. 



Slow. 



Often un- 
recognized 



Uraemia. 



Etiology . — Here, as in arterio-sclerosis and aneurism, the worship 
of Venus, Bacchus and Vulcan, form the primary factors in causation, 
though to this group may be added Mars, Minerva and Mammon. 
In other words, over-work, mental and physical, syphilis, sexual 
excess, exposure and privation, heavy eating and drinking, all play a 
prominent part. Arterio-sclerosis is a prominent feature in cases 
of interstitial nephritis, and one is not surprised to find what seems like 
a direct hereditary influence in the development of the latter disease. 
Lead poisoning, chronic malaria, gout and lithaemia, are common 
and prominent causative factors. As in the case of arterio-sclerosis 
proper, we find examples of the old young man, old by virtue of inherited 
vascular weakness or gout, or through sexual excesses, syphilis, or exces- 
sive mental strain. 

General Symptomatology. — The pallor, edema and the frankly 
albuminous and cast filled urine of chronic parenchymatous nephritis 
makes mistaken diagnosis unpardonable, but the reverse is true in 
chronic interstitial nephritis. In the earlier stages of the disease a 
patient may appear to enjoy unusually good health, this being partic- 
ularly true of the gouty type of the disease. Pallor, edema, and 
pigmentation are late symptoms, and the urinary findings are some- 
times both variable and obscure. Many cases die unrecognized. In 
many more, the diagnosis is made only at autopsy and the various 
manifestations of uraemia may never be traced to their true cause. Much 
i dependence must be placed upon the secondary signs in the heart 
and blood vessels, and the urinary examination demands care and the 
I intelligent application of a full knowledge of the vagaries of this extra- 
I ordinary disease. The general symptoms are essentially those of 
; uraemia, which may be present at any time in any of its various forms, 
I or may be postponed to the very end of the case. (The section on uraemia 
I should be carefully reviewed.) 

Circulatory Signs. — Advanced interstitial nephritis is invariably 
Important, attended with increased pulse tension, as indicated by an over-acting 
or hypertrophied left ventricle, a hard radial pulse, and a marked accen- 
tuation of the aortic second or mitral first sound, with or without redupli- 
cation. Edema. When marked edema appears in this disease, it is 
usually due to cardiac failure, and shows the characteristics of a passive 
congestion edema, the most dependent portion being first involved, 
as is the case in valvular disease of the heait. In many cases of inter- 
stitial nephritis, however, one may see the curious fullness of the eye-lids, 
especially the lower, presenting in the morning a tense appearance, 



Essentially 
cardiac. 



Sugges- 
tive sign 



DISEASES OF THE KIDNEY — NEPHRITIS. 



3^3 



the skin being thin, pearly, and almost translucent, while later in the 
day, the fluid may have disappeared and the delicate integument falls in 
fine wrinkles. Many of the cases fall under the head of a mixed neph- 
ritis, to be described more fully later on, and in these the renal facies is 
likely to be more marked and unmistakable, owing to the presence of a 
parenchymatous element. 

Changes in the Fundus. — In these as in other forms of renal dis- 
ease, the eye changes may be pronounced and important, indeed, 
many cases are referred by the oculist under a correct diagnosis, 
without urinary examination. The usual changes consist of 
flame-shaped hemorrhages, papillitis, retinal edema, or peculiar fawn 
colored patches, radiating from the macula lutea. (See Fig. 1, Plate 
VII.) Glaucoma is not uncommon, and uraemic amaurosis may occur. 
As a rule, these eye changes indicate a fatal termination in a short 
period, yet the author has observed one case in which the original 
diagnosis was made by the oculist, and a subsequent glaucoma led to 
enucleation of the affected eye; yet the patient is still living after 
seven years in apparent good health. 

Respiratory Tract. — It is important to remember the special liability 
of renal cases to attacks of bronchitis, pleurisy, asthma, edema of the 
glottis and dyspnoea in its various forms. A pleurisy with large effusion 
may come on so quietly as to attract no attention save through embar- 
rassment in respiration. In a case recently observed the acute edema 
of the laryngeal tissues that followed a sharp attack of tonsillitis, proved 
to be due to an acute congestion superimposed upon an old nephritis 
of the arterio-sclerotic type associated with passive congestion. 

Urinary Findings. — The essential symptoms consist in the increased 
amount of night urine, attended by increased frequency of micturition. 
a total increase for the 24 hours, a tendency to diminution in the 
total amount of solids, traces of albumin and a few hyaline and granular 
casts. Increased night frequency may be due to causes other than 
nephritis, such as enlarged prostate, chronic irritability of the neck of 
the bladder, or cystitis, but when the symptom is associated with a 
marked disturbance of the normal ratio between night and day, the 
symptom becomes one of primary importance. 

Diminution of Solids. — A man with interstitial nephritis may for 
years pass, the greater part of the time, a normal amount o\ urinary 
solids. In the latter stage of the disease it will almost invariably fall 
below normal, and this is especially true of urea. Variable information 
is often given by sudden drops in urea excretion and in a ease under elose 



Mixed 

form. 



Readily 
recognized. 



Prognostic 
value. 



Pleurisy, 
asthma, 
glottic 
edema, etc. 



Increased 
quantity. 



Night 

\ -. 
Pay. 



Urea 

\ ariations. 



3 6 4 



MEDICAL DIAGNOSIS. 



Important 
data. 



Typical 
cases. 



observation, it is often possible to avert an impending attack of uraemia 
through this warning. Albumin. Albumin may be present continu- 
ously or intermittently, at one time of the day and not at another, but 
in uncomplicated cases will be found only in small traces. The speci- 
mens least likely to show it are those passed in the early morning, those 
most likely being the ones voided several hours after a full meal, taken 
in the middle of the day or a heavy dinner at night. Both physical exer- 
tion and the process of digestion seem to increase the albumin. An ex- 
amination of the single specimen, even of the 24 hours urine, proves no 
man free from interstitial nephritis. Color. Usually pale. Specific 
Gravity. Low. 1002-1014. Total amount 2000-4000 c.c. May reach 
7000 or 8000 c.c. Reaction. Faintly acid, or neutral. Urinary Solids. 
Diminished, coloring matter diminished, except indoxyl, which is usu- 
ally increased. Albumin. Usually a trace, rarely reaches \ of 1% in 
the later stages. 

Sediment. — Usually slight. Casts are chiefly hyaline and 'faintly 
granular. A few renal cells may be found. Some cases are associ- 
ated with cylindroid storms. 

Symptoms of the Terminal Stage. — There may be passive con- 
gestion due to a failing heart, resulting in an increased amount of albu- 
min, and as a rule more numerous casts showing coarser granules and an 
occasional waxy cast. The amount of urine is diminished, the total 
solids are low, though the specific gravity may be relatively high. 
The general appearance of the patient is that of a cardiac edema, but 
it is extremely difficult to do anything for such a case. 

Prognosis. — No one knows for how long a period the changes of 
interstitial nephritis may endure in the living organism. It is safe 
to assume that cases have lasted for 40 or 50 years, and that the average 
duration is long. Through inheritance of cases, the author has been 
| able to follow T patients through a known period of at least 25 years, and 
is prepared to believe that some of them will add a decade more before 
the end comes. Cases are greatly jeopardized by the occurrence of 
subacute attacks which may be sufficiently severe to produce symp- 
toms of acute congestion, or so mild as to show little more than a few 
blood cells or epithelial casts. The occurrence of the change in the 
back -ground of the eye, symptoms of cardiac incompensation and the 
appearance of wax} 7 casts usually mean that the terminal stage has 
been reached. 

CHRONIC DIFFUSE NEPHRITIS WITH EXUDATION.— 
This disease represents clinically and pathologically a combination of 



Casts and 
cells. 



Cardiac 
symptoms. 



Urinary 
findings. 



Duration 
indefinite. 



Subacute 
attacks. 



Prognostic 
factors. 



DISEASES OF THE KIDNEY — FLOATING KIDNEY. 



365 



parenchymatous and interstitial forms. Many such cases are met 
with in practice. 

Etiology. — The causes are those given for the individual lesion. 

Symptoms. — The general symptoms are those of chronic interstitial 
nephritis plus a more decided primary and terminal edema, a more 
varied sediment, and a marked ancemia. 

Urinary Findings.— Quantity. Usually increased, varying from 
1500-3000 c.c. Color. Pale or with a slight greenish cast. Reaction. 
Neutral or acid Specific Gravity. From 1004-1015. Total Solids. 
Markedly diminished. Albumin. Average between \ and \ of 1%. 
Sediment. Hyaline and granular casts more abundant than in ordinary 
interstitial nephritis, and carrying fat in most instances, occasional 
fatty casts are found, and in advanced stages waxy casts. It will be 
noted that the symptoms throughout are those of parenchymatous and 
interstitial nephritis blended, and that they correspond accurately 
to the pathological changes. 

AMYLOID KIDNEY. — From the urine alone the diagnosis cannot 
be made in this disease but the presence of conditions with which it is 
known to be associated, viz.: — amyloid degeneration of other organs, 
usually occurring in the presence of chronic suppuration or cachexias, 
is suggestive. Polyuria with a large amount of albumin, hyaline casts 
in variable numbers, associated not infrequently with granular and 
occasionally fatty and waxy casts, constitute the urinary findings, the 
most significant feature of which is the usual combination of polyuria, 
low specific gravity and a large albumin content. 

MOVABLE AND FLOATING KIDNEY.— The normal kidney 
may or may not be palpable, but usually its lower border may be 
detected under proper conditions of muscular relaxation and correct 
technique. To palpate the kidney, one hand should be placed over 
the floating ribs behind, the other below the costal margin on the outer 
side of the rectus in the mammillary line. By steady firm pressure the 
two hands should be approximated, and during full inspiration allowed 
to separate slightly when the movable kidney may be felt to pass 
between them, and may be directly engaged and palpated during the 
manoeuvre. No attempt should be made to grasp the kidney primarily, 
and in any event, it should be engaged between the fingers of the two 
hands by simple approximation rather than by any grasping or clutch- 
ing movement such as is sometimes recommended. Though, ordi- 
narily, such an examination can be carried out when the patient is 
in a dorsal position, it is often useful to examine them in a position 



A common 
type. 



Mixed 

type. 



Basis of 
diagnosis. 



Technique 

of palpa- 
tion. 



Patient s 

attitude. 



3 66 



MEDICAL DIAGNOSIS. 



Author's 
preference. 



Movable 

vs. 
"Floating. 



Dubious 
factors. 



Curious 
variability. 



Dietl's 
crises. 



Misleading 
cases. 



between the dorsal and the lateral, the arm on the side under 
observation being allowed to hang loosely forward, and the pa- 
tient receiving some support to relieve the abdominal tension. 
Degrees of Renal Displacement. — The palpable kidney is one 
whose lower edge can just be felt by the examiner. Such a kidney is 
not abnormal; the movable kidney is that which slips back and forth 
like a "pea in a pod," or one which can be fixed by passing the examining 
fingers above its superior border during full inspiration. The term 
floating kidney is applied to those having more than a vertical dis- 
placement, or such as are vertically displaceable to a lower level than 
the umbilicus. The range of mobility is often extraordinary and in 
some instances the kidney may be found in the pelvis. 

Etiology. — The disease may be congenital, but is ordinarily acquired. 
It is far more common in women than in men and most often observed 
in multipara. About three-fourths of the cases occur on the right side 
and in about one-seventh the condition is double. Congenital relaxation 
of the ligaments, tight lacing and repeated pregnancies, the wasting of 
the peritoneal fat of the capsule, traumatism, muscular strain and other 
alleged causes must be placed in the "not proven " class. It is probable 
that in many cases a combination of these causes may be operative. A 
curious relationship seems to exist between movable kidney and 
appendicitis, the two conditions being often coincident. 

Symptoms. — Strange to say cases of extreme movability may exist 
without any symptoms, while slight cases may cause the most in- 
tense crises and no adequate explanation of this fact has ever been 
given. It is often wise to withhold information from the patient 
where no symptoms seem to be present, or where the condition is 
incidentally or casually encountered. When symptoms are present 
j they vary from those of mild neurasthenia and dyspepsia to the remark- 
able crises first described by Dietl. These are attacks sudden in onset, 
characterized by severe abdominal pain, nausea, vomiting and in extreme 
cases by chill, fever, and even symptoms of collapse. The utmost care 
should be observed in diagnosis, as errors are astonishingly frequent. 
In one case coming under the author's observation, a young unmarried 
woman had double floating kidney. She was subject to attacks of 
violent pain referred to the region of the gall bladder, and associated 
with jaundice. A noted surgeon was so far misled as to operate for 
cholelithiasis without result. In another case, precisely similar attacks 
occurred without jaundice, and the case was referred to a surgeon for 
a fixation operation. Symptoms continued after operation and a sub- 



DISEASES OF THE KIDNEY — PYELITIS. 



3 6 7 



sequent incision revealed a gall bladder full of stones. In another 
instance a co-existing appendicitis was found to be the real source of 
the pain. The author ventures to express the opinion, founded upon 
somewhat extensive opportunity for observation, that true DietVs crises 
are relatively rare; and that the appendix, gall bladder or gastric ulcer 
are more likely to be essential factors. Cases have been reported in 
which the condition has been confounded with renal colic, but such an 
error should seldom occur. The co-existence of profound neurasthenia 
and hysteria often complicate the examination. The association of 
movable or floating kidney with the displacement of other abdominal 
viscera is described under Glenard's disease. 

PYELITIS AND PYELONEPHRITIS.— Definition. By a pye- 
litis is meant an inflammation completely or chiefly confined to the 
pelvis of the kidney, by pyelonephritis an inflammation involving both 
the kidney substance and the pelvis. The former can hardly exist with- 
out a slight invasion of the kidney texture. Etiology. — Various 
micro-organisms are capable of causing these conditions; amongst these 
are: — the pyogenic streptococci, staphylococci, typhoid and colon bacilli, 
gonococci and tubercle bacilli. Infection in these cases is usually as- 
cending, the bladder or ureter being the primary source. They may, 
however, arise in connection with certain virulent acute infections, or 
in those of the chronic sort, and under these conditions, the infective 
agent would appear to be brought direct by the circulation. Renal 
calculus is a potent cause, yet stones may exist for years in a kidney 
without causing any marked disturbance. 

Symptoms of Pyelitis. — An acute pyelitis is ushered in by fever, 
pain in the back, or tenderness in the region of the twelfth rib, and usu- 
ally marked by frequent micturition. The urine in acute cases is dimin- 
ished in amount, of high acidity, and contains pus in quantity. The 
pain even in simple suppurative pyelitis may be so severe as to simu- 
late renal colic (see page 63), and may radiate in the same way to the 
groin, inner side of the thigh or testicle. Chill and fever may occur 
at any time during the course of an acute process; certain cases have 
been mistaken for malarial fever on this account. Occasionally, the 
ureter of an affected kidney becomes blocked, and retention on the 
part of the unsound kidney permits the excretion of normal urine 
from the sound side. So, also, masses of stringy pus and debris mav 
produce obstruction at the neck of the bladder, and pain simulating 
that of stone in the bladder. The urinary sediment shows large 
quantities of pus, a variable amount of blood, usually oi the slightest 



Dietl's 

crises rare. 



Frequent 
associa- 
tions. 



Usually 

ascending 

infection. 



Septic and 
renal. 



Colic. 



Temporarj 
blocking. 



Sediment. 



368 



MEDICAL DIAGNOSIS. 



Forms. 



Extent. 



Frank 

vs. 
Latent. 



Dysuria. 



Tempera- 
ture. 



Associated 
lesions. 



Not always 
progres- 
sive. 



quantity and the more or less characteristic cells of the renal pelvis 
(see figs. 135, 137). Ordinarily one will find also a few renal cells and 
an occasional cast. Under prompt and efficient treatment these symp- 
toms rapidly subside so that in a period varying from a few days to 
two or three weeks, an uncomplicated case may recover. 

Symptoms of Pyelonephritis. — These are essentially the same as 
those of pyelitis, save that the amount of pus is usually greater and 
sediment shows a decidedly greater number of renal elements. It will 
be noted that the characteristic features consist of (a). An acid urine. 
(b). Containing pus. (c). Yielding a sediment showing characteristic 
elements, i.e., casts, renal and pelvic epithelium. The picture may be 
much obscured by the presence of a cystitis in which case the urine 
may be ammoniacal, and the sediment may be so profuse, and with 
such predominance of the cystic elements as to greatly complicate the 
diagnosis. 

RENAL TUBERCULOSIS.— This occurs in two forms, the acute 
miliary which is merely a part of a general tuberculosis and the so- 
called caseous form which is of great clinical interest. The latter com- 
mences usually as a miliary or larger nodule which undergoes much 
i the same changes as would occur in other portions of the body. 
Either one or both kidneys may be affected and the process frequently 
involves the whole urinary tract including the urogenital apparatus. 

Diagnosis. — The diagnosis may be extremely easy or surprisingly 
obscure, the development being in some cases that of a frank tubercu- 
! lous pyelitis or pylonephritis, in others pursuing a latent course with 
no symptoms save those of irritation. In every case attention should 
be given to the organs so often secondarily affected, such as the spermatic 
cord, testis, prostate, and in the female the ovaries and tubes. So also 
persistent dysuria without signs of bladder disturbances sufficient to 
account for the condition will oftentimes prove to be of tuberculosis 
origin. In most cases there is a slight elevation of temperature and 
in a goodly number tuberculosis, present or past, or sufficient family 
history is made evident .Symptoms of lithiasis may co-exist and com- 
plete the picture. The affected kidney may or may not be movable 
primarily and in some instances becomes greatly enlarged and readily 
palpable. The author's experience has not been such as to permit 
him to coincide with the opinions expressed by some of our best sur- 
geons that the tuberculous change is of necessity a progressive and 
destructive one. In a considerable number of instances of slight 
involvement and several which presented a double tuberculosis so 



DISEASES OF THE KIDNEY — CYSTITIS. 



369 



advanced as to forbid operation the process has shown the same tend- 
ency to arrest as is so often observed in the lungs. Finally, the diag- 
nosis must depend upon the finding of the tubercle bacilli in the urine 
and their differential staining by proper methods and it must be remem- 
bered that they may be found in urines showing but the slightest traces 
of pus* In some instances the use of tuberculin is justifiable and may 
be followed by an appearance of the bacilli in the urine. 

Renal Tumors. — Their general characteristics have already been 
described on page 231 and the subject is one for surgical rather than 
extended medical discussion. 

HYDRONEPHROSIS.— Definition. By hydronephrosis is meant 
an over-accumulation of urine, within the kidney and some por- 
tion of its ureter, due to obstruction. A persistence of this condi- 
tion may result in a conversion of a kidney into a large cyst. Etiol- 
ogy. — The condition may be temporary or permanent, persistent 
or intermittent, and it may be either congenital or due to disease. 
Amongst the causes are stricture of the ureter or urethra, calculi, 
clots, a twisted ureter, such as occurs in floating kidney; or from neoplasm 
in the genito-urinary tract, or involving structures in close relation to it. 
The condition is commonly temporary and intermittent, but due in 
most instances to temporary torsion, pressure or removable obstruction. 

ACUTE CYSTITIS.— Etiology.— An acute inflammation of the mu- 
cous membrane of the bladder may be due to injury or irritation from 
calculi, foreign bodies, wounds and the introduction of sounds, or may be 
associated with urethritis, tuberculosis, prostatitis or mere exposure 
to cold and wet, sexual excess or the toxaemia of infectious diseases. 
Symptoms. — Dysuria with increased frequency and marked tenesmus 
are the chief symptoms, though pain may be severe and radiate to the 
perineum, the glans, hypogastrium or thighs; fever is usually slight 
and may be absent. The urine is scant, strongly acid, of variable, 
usually high specific gravity and contains an approximately normal 
amount of solids, albumin, blood and pus in variable quantity. The 
sediment consists of pus and blood cells in quantity with much bladder 
epithelium and numerous round cells. 

CHRONIC CYSTITIS. -This may result from an acute attack or 
may insidiously develop as the result of enlarged prostate, stricture, the 
frequent use of the catheter, infection from the genitals (female) and oi 
Course from calculi, growths or tuberculous process affecting the viseus. 

* In two cases recently observed the urine was almost clear and the only 

Subjective symptom a slight dragging pain over the kidney. 
24 



Tubercu- 
lin test. 



37° 



MEDICAL DIAGNOSIS. 



Like every other hollow, muscular organ, the changes may be either 
atonic or hypertrophic and in many cases of long standing the bladder 
is greatly contracted and tends to become incrusted with urinary salts. 
Symptoms. — These are those of the acute form, usually in a milder 
degree both as to subjective symptoms and urinary findings, though in 
the latter .blood is less likely to be present in quantity, and the reaction 
is more likely to be alkaline and show the presence of the volatile agent, 
ammonia. The solids are usually somewhat diminished, the sediment 
will show triple phosphate and often ammonium urate crystals in the 
presence of an alkaline reaction. 

Comment. — It should be noted that these cases lack all evidence of 
renal involvement and that the albuminuria present is usually in direct 
proportion to the blood or pus from which it is derived. 

TUBERCULOSIS OF THE BLADDER.— A chronic cystitis 
presenting no symptoms of stone, stricture or enlarged prostate should 
always suggest tuberculosis. It usually involves primarily the trigone 
and the urethral orifices. The seminal vesicles and prostate should 
always be examined for nodular infiltrations and weight should be given 
to recent hemorrhages. Symptoms. — The appearance is that of a 
severe or mild chronic cystitis, with or without hemorrhage, but asso- 
ciated usually with acid urine. The diagnosis depends upon the find- 
ing of the tubercle bacilli, and the use of the cystoscope. 

TUMORS OF THE BLADDER.— These fall properly under sur- 
gery and it need only be said that papillomata are the most frequent, 
aside from malignant growths of advanced age, and that they produce 
chiefly symptoms of chronic cystitis associated with marked intermit- 
tent haematuria. Occasionally bits of the growths may appear in the 
sediment, together with shreds of tissue and caudate cells from the villi 
of the growth. 

ACUTE PROSTATITIS.— This may result from the same causes 
that lead to an acute cystitis and is recognized by the swelling, heat 
and tenderness of the gland, associated with throbbing, pain in the back 
and legs, dysuria and constant urgency, both rectal and vesical, with 
marked tenesmus and increase of pain attending the end of urination. 
Casts of the prostatic ducts may be present in the sediment and occa- 
sionally spermatozoa, otherwise the urinary picture resembles acute 
cystitis. Complications. — Prostatic abscess may develop and is usu- 
ally associated with known symptoms of sepsis and may cause mechan- 
ical retention of urine. 

CHRONIC PROSTATITIS.— This is most frequent at advanced ages 



CHEMIC EXAMINATION OF URINAKY CALCULI. 



371 



in connection with chronically enlarged prostate but may also follow 
acute attacks or be associated with chronic posterior urethritis. The 
association of modified symptoms of the acute form associated with 
palpable hypertrophy or swelling of the prostate and the symptoms 
of chronic cystitis make the diagnosis. 

Chronic Urethritis. — Need not be considered in this volume. 

URINARY CALCULUS.— This most commonly occurs in the 
bladder or renal pelvis but stones may occupy the ureters and vary in 
number from one to several hundred, and in size from a mere grain to 
that of a large orange. They vary greatly in form, usually assuming 
the shape of the cavity in which they lie and occasionally being pol- 
ished by attrition when several lie in contact. Uric acid, cystin and 
phosphate present usually a smooth surface and the calcium oxalate 
stone is lobulate and rough (mulberry calculus). Uric acid and urates 
vary in color from pale yellow to deep brown, phosphatic stones are 
grayish or white, those of calcium oxalate deep brown, of cystin, yel- 
low. Section should always be made to determine the constituents as 
several concentric layers may be found. As to frequency, uric acid and 
urate stones predominate. In all forms the urinary sediment is likely 
to furnish suggestive findings during the stage of stone formation con- 
taining the characteristic crystals of uric acid, ammonium or sodium 
urate or calcium oxalate or triple phosphate crystals, etc., according 
to the nature of the process. 

Tests for Urinary Calculi. — The concentric layers should be sawed 
through and tests made from the scrapings of the different layers and 
of the powdered nucleus. The following table is taken from Dr. J. 
B. Ogden's admirable book.* 

CHEMIC EXAMINATION OF URINARY CALCULI. 
1. Preliminary Examination. — Heat on platinum foil: 

Albumin=a. flame with odor of burnt horn. 

Urostealith=^a, flame with odor of shellac and benzoin. 

Cyslin=& blue flame with odor if SO a . 

Xanthin and uric aad— char without a flame. 

Alkaline urates -= alkaline residue soluble in H„0. 

Earthy phosphates—- a residue soluble in acetic acid without effer- 
vescence. 

Calcium oxalate and calcium carbonate a residue soluble in acetic 
acid with effervescence, 

* Clinical Examinations of the Urine and Urinary Diagnosis. 



372 MEDICAL DIAGNOSIS. 



Calcium carbonate — original powder soluble in acetic acid with 

effervescence. 
Calcium oxalate= original powder insoluble in acetic acid. 
Silica = residue insoluble in HC1. 
Murexide Test for Uric Acid.— Original powder + HN0 3 and 

evaporate = pink residue + NH 4 OH — purple color=uric 

acids and urates. 

Original powder + HN0 3 and evaporate + KOH= violet 

color, which disappears on heating — uric acid. Violet increases 

on heating — xan thin. 
Systematic Examination. — Presence of uric acid shown by (i). 
Boil in H 2 and filter. 

A. Filtrate -r HC1. Let stand 24°-=crystals of uric acid. Bases 
in solution. Concentrate. 

Calcium wrate=one drop of solution + solution ammonium oxa- 
late =crystals calcium oxalate. 

Magnesium urate=onedrop of solution + NH 4 OH +Na 2 HP0 4 
= crystals ammonio-magnesium phosphate. 

Sodium urate=one drop of solution + Pt. CI 4 = after concentra- 
ting, prisms of sodioplatinic chloride. 

Potassium urate and ammonium urate=one drop of solution + 
Pt.Cl 4 — dodecahedra of potassioplatinic chloride and ammo- 
nioplatinic chloride. 

Potassium Urate. — Evaporate solution and ignite on mica. Res- 
idue -f HCl-f Pt. CI 4 = potassioplatinic chloride 

Ammonium Urate. — Evaporate solution and ignite on mica. Res- 
idue = no crystals with Pt.Cl 4 . 

B. Portion insoluble in H 2 0. Add HC1. 
Uric acirf— insoluble. 

Calcium carbonate=so\vk>\e with effervescence. Filter -t- NH 4 - 
OH = precipitate of calcium oxalate, calcium phosphate, and 
ammonio-magnesium phosphate. Wash. Calcium oxalate= 
insoluble in acetic acid. Filter -+- ammonium oxalate to filtrate. 
Calcium phosphate gives precipitate of calcium oxalate. Filter 
+ NH 4 OH to filtrate = precipitate of ammonio-magnesium 
phosphate. 

GLYCOSURIA. — (Sugar in the Urine). Clinical Definition. In a 
clinical sense glycosuria comprises all conditions under which the urine 
contains grape-sugar (glucose) in sufficient quantity to respond to the 



GLYCOSURIA. 



373 



Intermit- 
tent cases. 



Important. 



Temporary 
recession. 



ordinary tests. In short, all diabetics have glycosuria, but all who have 
glycosuria are not diabetics. Sugars of various kinds may be found Glucose 
in the urine, but glucose is the one of especial interest to the physician . 
Normal urine contains it, as it does albumin, but not to an extent that 
can produce any confusion in clinical work ; hence any urine that shows 
sugar when tested, according to methods here recommended, is abnormal. 
Furthermore, glucose or dextrose may appear either persistently or 
intermittently in the urine of apparently healthy persons and no sharp 
line separates the benign from the pathologic condition, save that 
suggested by Stengel, who says that all cases fall under one of two classes, 
viz.: — ist those easily controlled (simple glycosuria), 2nd those that are 
intractable (diabetes mellitus). The urine of one who takes into a 
fasting stomach phloridzin or large quantities of glucose, a woman 
recently delivered, or the man with a brain injury may temporarily 
contain sugar. The stout high living individual may carry such a 
condition for many years (lipogenic diabetes) without serious impair- 
ment of health; but lapse of time alone suffices to prove the benign nature 
of any given case. Glycosuria may entirely disappear for long periods, 
only to recur, and not infrequently to assume a malignant orm. 
Such periods of latency cannot be justly estimated, and the very causes 
that are assigned for benign glycosuria are quite commonly associ- 
ated with the development of diabetes mellitus. The conditions under 
which diabetes develops are in brief the following: — Age. — It occurs at 
all ages, but chiefly in the fifth and sixth decades. Its prognosis is 
inversely as the age of the individual. Children rarely recover, and in 
them, the course may be astonishingly acute. Sex. — 80% of the cases 
occur in males. Race. — Certain races suffer greatly from disease. In 
Tunis and in Malta its ravages are comparable to those of tuberculosis 
in European countries. This, however, applies chiefly to city dwellers. 
Hebrews are especially liable to the disease. An enormous increase 
has been noted in certain cities during the last three decades. In 
Danish cities and in Paris, for example, the mortality is said to have 
quadrupled during that period. Due allowance must, of course, be 
made for improved diagnostic methods. Heredity is very marked. 
Schmitz reports that diabetes has occurred in the blood relations of 
998 of the 21 15 individuals whose cases he had investigated, fourteen 
Cases having been reported in one family. Diet. Digestive glycosuria 
is under certain conditions quite unimportant. Van Noorden would 
place a definite limit to the amount of sugar that should be disposed of 
under normal conditions, without producing glycosuria, and various 



Etiolosy 



374 



MEDICAL DIAGNOSIS. 



Arthritic 
glycosuria. 



Lipogenic. 






writers have suggested a test amount vaiying from ioo to 250 gm., 
this to be taken at one sitting, and on a fasting stomach. If sugar then 
appears in the urine, the individual is a suspect. It is said that in such 
cases the sugar excreted is of the same variety as that ingested. Exer- 
cise. — There can be no doubt that a rich diet, associated with seden- 
tary habits and great mental activity, are potent factors in causation. 
Gout. — Gout is distinctly associated with diabetes, though it is claimed 
that the arthritic form is comparatively benign. The reason for such 
an association is evident, the same habits of life and hereditary elements 
being present in both diseases. It should be noted, however, that the 
consumption of alcohol is not often a prominent factor in the causation 
of glycosuria. Diseases Antecedent or Complicating. — Aside from 
those mentioned in the opening paragraph, gout, tuberculosis and 
nephritis are commonly associated with diabetes, the two latter being 
usually secondary conditions. Obesity. — A large number of glycosu- 
rics are obese, and this lipogenic form is ordinarily easily controllable 
and often curable, nevertheless, many cases apparently benign at the 
outset become true diabetes. Pancreatic Disease and Sclerosis of 
the Spinal Cord. — It is probable that about one-third of the cases 
of diabetes are pancreatic in origin. Sclerosis of the cord may be sec- 
ondary or primary, and the relationship of the two conditions has not 
been sufficiently worked out. 

Symptoms. — The so-called "three P's," Polyuria, Polyphagia, Poly- 
dypsia, represent the fundamental symptoms as seen in a typical case 
and the thirst and increased frequency of urination and large amount 
of urine are usually the first symptoms noticed. An excessive appetite 
is seen in nearly all advanced cases. Rapid loss of weight and strength 
is marked in true diabetes and often prominent in the benign forms. 
The Skin. The skin is dry, eczema, boils, carbuncles are common and 
gangrene is often a terminal complication. The Eye. Neuro-retinitis, 
hemorrhage and cataract are often seen. Muscles. Besides pro- 
nounced weakness, muscle cramps are common in advanced cases. 
Sexual Organs. Impotence, amenorrhcea, pruritus vulvae and balanitis 
occur and pregnant women are likely to abort. Nervous System. 
Neuritis, headache, mental irritability or depression, drowsiness or 
insomnia may occur, true melancholia may develop, and in 50% of the 
severe cases the knee jerks are absent. Lungs. Pulmonary tubercu- 
losis is a common terminal event. 

Coma. — Diabetic coma may be the first recognized symptom of the 
disease. The author recalls a casual meeting on the street which led 



The three 
P's. 



GLYCOSURIA. 



375 



to the recognition of unsuspected advanced diabetes in the infant child 
of a friend, the babe dying a few hours later in diabetic coma. In 
this case the breath had the peculiar aromatic sweetness present in all 
cases of threatening coma and presumed to be due to the presence of 
acetone. Other premonitory symptoms are headache, drowsiness, 
nausea, vomiting, dyspncea and rapid pulse, the dyspnoea is a definite 
air hunger, the term accurately describing the symptom. Constipation 
is often marked and the symptom of mild or severe indigestion. In 
actual coma the breathing may be slow and the deep sighing, super- 
ficial or Cheyne-Stokes. Certain cases are characterized by profound 
collapse, and in others ataxic symptoms are prominent. The Blood. 
Bremer's test may be valuable in coma if for any reason a specimen 
of urine is unattainable. Two smears, one of diabetic blood, the other 
of normal blood are made in the ordinary manner. They are fixed by 
heat and stained for two minutes in a i% aqueous solution of congo-red. 
The diabetic smear remains unstained or shows a pale or greenish 
yellow. The control smear of normal blood is stained red. If methy- 
lene blue is used the diabetic smear takes a yellowish green, the normal 
blue. On the other hand, a solution of Biebrich-scarlet stains the 
diabetic smear scarlet and does not affect the normal blood. These 
blood reactions may reveal a glycaemia in the absence of glycosuria. 

The Urine. — Total quantity increased, the amount sometimes reach- 
ing or exceeding 20,000 c.c. The specific gravity is high, varying from 
1030 to 1060. Sugar varies from a mere trace to 8 or 12% in extreme 
cases. 

Important Variations. — It must be remembered that in glycosuria 
as in albuminuria the abnormal constituent of the urine may be totally 
absent for considerable periods, may be lacking at one time of the 
day and present at another, and that it may be wholly removed by 
careful dieting and proper medication, thus making it possible for a 
glycosuric to pass a life insurance examination. Furthermore, the spe- 
cific gravity is not always high, and a specific gravity of 1010 does not 
justify the omission of the test for sugar, as is so generally believed. 
No one of the cardinal symptoms is absolute, polyuria is not an invari- 
able symptom and as might be inferred both polyphagia ami polydypsia 
may be absent and even in true diabetes long periods of Latency may 
occur, The tests for sugar are dealt with on page 333. 

Diacetic Acid and Acetone. See page 338. 

Prognosis. The prognosis in glycosuria depends primarily upon 
the decision as to whether one is dealing with true diabetes or simple 



Important 
signs. 



Bremer's 
test. 



Glycaemia. 



Quantity 

and 

weight. 



Removable 

siiLrar. 



Low spe- 
cific cravi- 
ties, etc. 



376 



MEDICAL DIAGNOSIS. 



Important 
factors. 



Etiology 



glycosuria. If the former, the prognosis is always grave, if the latter, 
is favorable. In youth, the disease is almost invariably rapidly fatal, 
cures being extremely rare. The thin offer a more serious prognosis 
than the fat. The presence of diacetic acid is a dangerous signal 
calling for prompt measures of elimination such as would be used in 
threatening uraemia. Apoplexy, carbuncles, tuberculosis, gangrene and 
coma are distinctly terminal events. 

DIABETES INSIPIDUS.— This curious ailment, occurring usually 
during the first three decades of life, and more frequently in the male, 
may be induced by traumatism, violent emotions, acute disease, tuber- 
culous peritonitis, sunstroke, cerebral syphilis or tumor, diseases of 
the abdominal viscera, including aneurism. Heredity is sometimes 
evident and it may be congenital. Morbid Anatomy. — The lesions 
I consist merely of congestion and dilatation of the kidney and ureters, 
J and hypertrophy of the bladder. Various lesions of the nervous system 
j have been reported but none specific. Symptoms. — Excessive thirst, 
striking emaciation and a dry skin co-exist with the passage of enormous 
quantities of pale, faintly acid or neutral urine (5000 to 20,000 c.c.) dur- 
ing the 24 hours. The specific gravity is extremely low (1001 to 1005), 
yet the total solids for the 24 hours are greatly increased, urea often 
exceeding 100 gms. Albumin and casts if present at all are scant and 
of no significance and the sediment is negative ordinarily. 

Differential Diagnosis. — The disease is most commonly confused 
with interstitial nephritis but the mistake can seldom occur if the total 
solids are estimated as should invariably be done, an increase being 
the rare exception in the latter disease. Furthermore, the cardio- 
vascular symptoms of nephritis in any case likely to be confounded 
with diabetes insipidus would be marked. 

Prognosis. — This depends upon the cause of the disease. If asso- 
ciated with cerebral tumor or organic disease in any part of the body 
it is bad. Many of the idiopathic cases recover. 



Great 
quantity of 
light urine. 



Solids 
increased. 



Scope and 
value. 



DISEASES DEPENDENT UPON OR ASSOCIATED WITH 
CHANGES IN THE BLOOD AND DUCTLESS GLANDS. 

Examination of the Blood. — Haematology. — This recently devel- 
oped branch of medicine has proven invaluable to the internalist and 
useful to the surgeon, affording a means of exact diagnosis in malaria, 
the leukcemias, filariasis, relapsing fever, typhoid fever, Asiatic cholera, 
Malta fever and trypanosomiasis, fundamental evidence in cases of 
pernicious anamia, chlorosis, secondary anozmia, Hodgkin's disease and 



EXAMINATION OF THE BLOOD. 377 

diabetes mellitus and valuable corroborative evidence in the acute pneu- 
monias, appendicitis, septic injections, trichiniasis, lead poisoning, gout, 
malingering and certain cases of malignant disease. Indeed these are 
but a part of the large group and in addition one must consider the 
valuable information represented by negative findings. Thorough labo- 
ratory training and accurate, painstaking work are essential to success 
and superficial or theoretic knowledge is of little value. 

Clinical Essentials. — (a). The determination of hemoglobin, (b). 
The. red cell count, (c). The white cell count, (d). The examination 
of fresh blood, (e). The examination of the smear preparation (a. 
stained, b. unstained), (f). The study of the various "clump" or 
agglutination reactions in certain acute infections (serum diagnosis). 

Clinical Tests of less Importance. — (a). Counting blood plates, 
(b). Estimation of alkalinity, (c). Cryoscopy. (d). Specific gravity 
determination, (e). Coagulation period, (f). Determination of blood 
volume and ratio of corpuscles to plasma.* 

Terms in Common Use. — Anaemia. A deficiency in corpuscles, 
coloring matter, or total blood volume. Oligocythemia . A deficiency 
of red cells. Oligochromcemia A deficiency in haemoglobin. Oligemia. 
Deficient blood volume. Leucocytosis. The term is commonly used 
to denote an abnormal increase in the number of leucocytes the polymor- 
phonuclear type predominating. The average per cubic millimeter is 
normally about 7,500. Lymphocytosis. An unusual increase in the 
number of mononuclear leucocytes. Leucopcenia. The opposite of 
leucocytosis and equivalent to hypoleucocylosis. Plethora. A term 
covering what was formerly supposed to be a pathological condition, 
but now used to indicate an increase in the total quantity of blood. 
The term " plethoric" is applied to those individuals with a ruddy 
countenance due to dilated or unusually prominent capillary network. 
The condition is now of slight clinical importance, though it is certain 
that there is a direct relation of the blood volume, to the musculature 
and the size of the heart. Polycythemia, an abnormal increase in the 
number of red cells may, rarely, be a symptom of importance, particu- 
larly when associated with enlarged spleen and cyanosis (Osier's dis- 
ease) or acetanilide addiction. 

♦ This section naturally reflects not only the author's personal experience 
but the teaching of Thayer, Simon, Cabot, Hewes, DaCosta, Ewing and E. 
S. Wood as conveyed by their published work, or, in the case of the first 
four, by persona] instruction or communications, Nevertheless the publi- 
cations 01 Ehrlich, Grawitz, Sahli, T. Laache, Neusser, Hayem, Durham, 
Scott and others have been freely consulted. 



378 



MEDICAL DIAGNOSIS. 



' 



Term 
defined. 



Steriliza- 
tion. 



Bleeders. 



Best in- 
strument. 



Method. 



Form and 
size. 



Prepara- 
tion. 



Color Index. — The color index represents the result obtained by 
dividing the haemoglobin percentage by the percentage of red cells, the 
normal for haemoglobin being ioo; and 5,000,000, cells in men, or 
4,500,000 in women, being the assumed normal for erythrocytes.* 

To Obtain Blood for Examination. — It is essential that the actual 
technique should be thoroughly understood, and intelligently and 
expeditiously carried out. 

Precautions. — One should not trust to the flow of blood for sterili- 
zation. The ear lobe or the finger tip should be carefully cleansed 
with alcohol, bay rum, cologne, or some similar substance always 
available, and the needle or lancet used should be sterilized in the flame. 
The patient should be asked whether he bleeds easily or the reverse with a 
view of determining the size, depth of the puncture, and of avoiding 
serious complications in cases of hemophilia. Two cases of this kind 
in the author's clinic bled steadily for several hours from a very minute 
puncture. For making the puncture an instrument with a sharp cutting 
edge should be used. The Hagadorn needle and the spring lancet 
with a trocar point, f are most suitable, the ordinary needles being 
poor substitutes. The puncture should be sufficiently free and deep 
to obviate squeezing or excessive friction, and furthermore, the instru- 
ment should be used with a sharp, quick painless stroke, J and the first 
two or three drops should be discarded. The blood should flow spon- 
taneously and to maintain it light friction may be used, but pressure never, 
and to check it firm steady pressure is sufficient, or in the case of the 
finger, vertical elevation of the arm. 

Care and Preparation of Slides and Cover-glasses. — All material 
should be of the best sort, f square cover-glasses being superior to the 
round, and both these and the slides should be thin. When received 
from the dealer, they should be thoroughly washed in soap and water 
and then placed in the following solution: — Hydrochloric acid, 1 part, 
absolute alcohol, 29 parts, water 70 parts, or they may be placed in 
solution containing equal parts of alcohol and ether. 1 1 When required, 

* Example 1. In a given case the haemoglobin is 30 #, the red cells num- 
ber 3,000,000, or 60%. 30 divided by 60 equals T \, a low color index indi- 
cating chlorosis. Example 2. Haemoglobin 30%, red cells 1,000,000 or 
20%. 30 divided by 20 equals 1.5; a high color index such as is found in 
pernicious anaemia. Example 3. Haemoglobin 50%, red cells 2,500,000 or 
50%. 50 divided by 50 equals 1; color index indicates secondary anaemia. 

t To be obtained of any instrument house. 

+ Blood may be taken from young children in this way without arousing 
them from sleep. 

1 1 The rapid evaporation of the latter constitutes an objection to its use. 



EXAMINATION OF THE BLOOD — SMEARS. 



379 




Fig. 146.— Blood smear 
Ordinary method. 



7.— Making blood 
with two cover- 



they should be wiped thoroughly, polished with tissue paper or with 
soft linen, and, if convenient, passed through a flame. A small drop 
of blood will spread satisfactorily and evenly between a perfectly clean 
slide and its cover-glass or between two cover- 
slips, especially if these are slightly warm. 

Making the Smear. — To make a good smear 
preparation the cover -glass must be absolutely 
clean and a small drop only should be lightly 
touched by one, the other placed quickly upon 
it, an instant allowed for the spread of the blood and the two separated 
by a sliding (not a lifting) movement as shown in figure 146. The 
cover -glass should never touch the skin. Another method consists in 
using the edge of one cover-glass and drawing it lightly across the 
drop, another of a similar procedure with micro- 
scope slides and in the use of the cigarette paper 
edge as shown in fig. 148. A good smear should 
show the cells evenly distributed throughout large 
areas and should not look to the eye smeary or 
thick. If carefully preserved the dry unstained 
specimen will keep for a long time* a matter 
often lost sight of by the physician. Forceps 
are not needed at any stage of the procedure but the stained preparations 
are more brilliant if the slip is immediately dried over a flame. 

Fixation of Dried Preparation. — The almost universal use of the 
Wright stain makes a prolonged description of the older methods unnec- 
essary. For rapid work with the triple stain it 
is sufficient merely to pass the smear through 
the flame rapidly 30 or 40 times with the clean 
surface down, much as in fixing the preparation 
for staining tubercle bacilli but with rather less 
heat. The same results may be obtained by 
boiling specimens for a minute in absolute 
alcohol, by fixing by one minute's immersion in 1% alcoholic solution 
of formaline, or by a few seconds' exposure to formaline vapor. The 
older heating methods are delicate, require for good results a special 
oven and arc not necessary for ordinary clinical work. 

Examination of the Fresh Blood. — Fresh blood is readily examined 

♦ Specimens in the author's possession have stained well after one or even 
two years, but there is a time limit, recent efforts to stain some six year 
old smears proving futile. 



Use. 



Correct 

technique 

essential. 





F i g. 148.— C i g a r e 1 1 e 
paper method of prepar- 
ing hlood films. 



Rapid fix; 
tion and 
staining. 



^ 



3 8o 



MEDICAL DIAGNOSIS. 



Extruded 
granules. 



Basis of 
staining 
methods. 



by allowing a small drop to spread evenly under a perfectly clean 
cover-slip and slide, both of which have been gently warmed. It may 
afford information of the greatest value in regard to the following 
conditions: — (a). Leukcemia. (b). Malarial organisms (and their amoe- 
boid movements if the stage is kept warm) * (c). Filariasis sanguinis 
hominis. (d). Relapsing fever, (e). Trypanosomiasis, (f). Rouleaux 
formation, (g). Increase of fibrin, (h). Increase of blood plaques. 
(i). Low color index, (j). Approximate number of red and white cells. 
(k). Cell deformity. Nucleated red cells are not to be distinguished 
by this method, and while it is possible for an expert to make a rough 
differential count of unstained leucocytes, such a step is seldom necessary 
or advisable. The presence of "blood dust" or haemochronia is indi- 
cated by a rapid vibration of these tiny bodies, which in all probability 
correspond to extruded cell granules. By sealing the edges of the 
cover-slip with a little vaseline one may preserve the fresh specimen 
for hours. 

Examination of the Stained Specimen. — The selective affinity 
shown by the different constituents of the cellular elements of the blood 
for certain aniline dyes affords a ready means of cell differentiation. 
The aniline dyes are divided into 3 groups (a) basic, (b) acid, (c) neutral. 
By using dyes of the various classes in combination in a single stain 
one may in a single step attain differentiation. The basic dyes, such 
as methyl violet, methylene blue or haematoxylin (chromatin stains) 
act chiefly upon nuclei. Acid dyes, such as eosin, orange G. or acid 
fuchsin are protoplasm stains, while neutral dyes (resulting from the 
mixture of acid and basic colors in solution) color beautifully the "neu- 
trophile" granules of the leucocytes. All modern methods of staining 
depend upon the recognition of this selective affinity. 

Staining Solutions. — Up to within a short time the favorite blood 
stain was Ehrlich's triacid or triple stain, but this has now been dis- 
placed by Wright's modification of Jenner's stain, an alkaline eosinate 
of methylene blue, which not only produces beautiful results, but 
at once fixes and stains the specimen, thus eliminating the laborious 
and delicate heating process of the older method.f 

Wright's Modification of Louis Jenner's Stain. — The student 
or practitioner had best purchase a solution ready made through some 

* Brownian movement and the contractions preceding crenation and cell 
death can hardly be confounded with true amoeboid movement. 

t The old eosin and haematoxylin or eosin and methylene blue mixtures 
are quite out of date in clinical work. 



EXAMINATION OF THE BLOOD — STAINS. 



381 



drug supply house, as the formula is somewhat complex,* and it should 
be kept tightly corked to prevent precipitation. 

Technique of Staining. — (1). The dried but unfixed smear, com- 
pletely covered with the stain is left one minute. (2). Then distilled 
water is added to the stain on the cover-slip drop by drop until a 
greenish metallic scum appears and the margins show a reddish tint. 
(3). After three minutes the stain is washed off with water, leaving a 
purplish specimen, which is washed until the film is yellowish or pink, 
(4) gently dried between filter paper, and (5) mounted in balsam. 

Results. — The appearance of the various cellular element is as 
follows: — Erythrocytes. Orange or pink throughout. Erythroblasts 
show deep blue nuclei, blood-plaques purple, mast cell granules deep 
purple, polymorphonuclear leucocytes show lilac or blue nuclei, neutro- 
phile granules lilac, eosinophile granules pink, fine basophile granules 
a deep blue stain, bacteria and such organisms as malarial parasites 
blue. 

Ehrlich's Triacid Stain. — The ready mixed powder for making 
this stain may be bought of any supply drug house and the student or 
practitioner should not attempt to make the original: — Formula: 
Ehrlich-Biondi powder gr. xv. Alcohol (absolute) 1. c.c. Distilled 
water 6 c.c. Fairly good rapid work may be done with a good triple 
stain in the absence of Wright's stain, by heating the smear carefully 
as in the staining of tubercle bacilli and staining for 30 sec, washing, 
drying and mounting (Cabot). Other heat fixation methods are now so 
little used that a description is not deemed necessary. Scott fixes by 
a few seconds' exposure to formaline fumes before applying Jenner's 
stain and shows beautiful results. 

Haemoglobin. — Haemoglobin or more properly oxyhemoglobin con- 
stitutes about 9-10 of the bulk of the red corpuscles. It is a proteid 
substance containing 4% of hamiochromogen, an iron holding body, 
and 96% of concentrated, almost insoluble albumin which readily 

* Formula. — (a). Make a 0.5 % aqueous solution of sodium bicarbonate, 
place in Erlenmeyer plaque, add 1 % of Grubler's medicinal methylene 
blue; place in steam sterilizer for an hour. (b). After cooling, add while 
stiiring with glass rod, a 1-1 000 aqueous solution of Grubler's water-soluble 
yellowish eosih until the color of the original mixture changes to purple 

and presents a lustrous yellowish scum upon its surface. (About \ as much, 
eosin solution as methylene blue solution will be found necessary.) (c). 

Collect this scum by filtration, dry it, and with it saturate methyl alcohol, 

(100 c.c. of the latter will dissolve aboul , :! oi a gram oi the dry precipi- 
tate), (d). Filter and add 25 % of methyl alcohol. The stain is now ready 

for use and should neither precipitate nor show impairment though kept for 
a long period. 



Rapid and 
simple. 



Action 
on cells 



3 82 



MEDICAL DIAGNOSIS. 



forms unstable compounds with oxygen. The great value of its deter- 
mination by clinical tests may be readily appreciated. 

Tests for Haemoglobin. — An expert observer can make a close esti- 
mate of the percentage of haemoglobin from the appearance of the ordinary 
stained or even the unstained smear preparation as may be readily appre- 




Fig. 149.— A. Normal blood. B. Chlorosis. C. Pernicious anaemia. The plate 
shows the sharp contrast between cells normally rich in haemoglobin and the light 
cell of chlorosis and also the poikilocytosis and marked variation in size noted in 
pernicious anaemia. (A normoblast and megaloblast also appear.) Stained smears. 

ciated by referring to fig. 149, but for accurate work several forms 
of apparatus have been devised, all depending upon a comparison of 
a given specimen of blood, either whole or in a known degree of dilution, 
with a fixed color scale. 

Tallqvist's Haemoglobinometer. — This, the simplest of apparatus, 
consists of lithographed color bands, each with a central perforation, 
and represents the color of blood in dilutions running from 10% to 
normal, when applied to absorbent paper.* A drop of the patient's 

* The color scale is bound with 50 sheets of special paper each divisible 
into three parts, furnishing material for 150 tests. 



EXAMINATION OF THE BLOOD — HtflMOGLOUINOMETERS. 



3*3 



blood is taken up by the absorbent paper and the resulting stain is 
placed under the central perforation of the color bands and comparison 
is made as soon as the stain has lost its wet gloss, not after complete 
drying. This is a simple, rapid but inaccurate method allowing probably 
10% variation, and the color scale fades, if not kept from the light. It 
is distinctly inferior to Dare's instrument which takes hardly a minute 
more of time. 

Dare's Haemoglobinometer. — A circular disc of tinted glass, rep- 
resenting variations in blood coloring matter of a known degree, is 
brought into direct contrast by transmitted candle light with a film 




Fig. 150.— Dare's h;cmoglobinometer. U. Obser- 
vation tube. T. Shield. YV. Removable plate with 
capillary opening for holding blood. X. Thumb 
screw for holding same. Y. Candle holder and 
candle. R. Milled wheel for revolving color disc. 
V. Aperture for illumination and color comparison. 
S. Case inclosing color disc. 



of the fresh whole blood drawn by capillary attraction between two 
glass plates, one transparent, the other translucent and white. A 
detachable observation tube and a circular shield, protect the eyes from 
extraneous light, and the percentage of haemoglobin may be read directly 
fiom the scale. The instrument may be used in daylight, but should 
be pointed at some dark object and its readings are not affected by an 
excess of leucocytes. 

Von FleischPs Haemoglobinometer. This well known instrument 
or its more accurate modification has been largely superceded by the 



3«4 



MEDICAL DIAGNOSIS. 



simpler and cheaper instrument of Dare. If it is used one should pro- 
cure Miescher s modification. The following precautions are necessary 
to good results: — (a). The capillary tubes for taking the drop must be 
absolutely clean and should be tested out for equality of calibration 
when purchased, (b). All blood must be remmed from the surface before 
mixing, leaving the calibre exactly filled, (c). The blood must be taken 
qukkly, washed out into the chamber, and thoroughly mixed in the short- 
est possible time. (d). The observer should face the end of the movable 




Fig. 151.— Von Fleischi's haemoglobin- 
ometer. Description. Milled wheel at right 
moves a tinted glass wedge under the 
fixed metal stage surmounted by double 
chamber reservoir which receives light 
from the calcium sulphate reflecting disc 
below. Half of the same chamber is filled 
with distilled water into which is stirred 
the blood contained in the measuring 
capillary pipette. The other contains only 
plain water but receives its light from the 
colored wedge. By moving the wedge 
back and forth the colors are matched and 
the percentage reading is shown on a scale 
visible through the opening just in front of 
the supporting upright. 




Fig. 152.— Oliver's haemoglo- 
binometer. The discs shown 
as white in the illustration are 
colored to represent the vari- 
ous blood dilutions and direct 
comparison is made with a so- 
lution of the actual blood ob- 
tained by a measured mixing 
capillary pipette furnished with 
the instrument. Intermediate 
readings are obtained by plac- 
ing squares of tinted glass over 
the fluid under examination. 



colored wedge with the thumb screw on his right, (e). Decision as to 
color should be made quickly to avoid uncertainty and confusion, (f). 
The thumb screw should be sharply turned in order to obtain as vivid a 
contrast as possible until the final match of color is achieved, (g). 
Should the blood solution appear turbid and lack proper color, as in the 
case of leukcemia, add a few drops of a dilute aqueous solution of potassium 
hydrate, (h). Where the hcemoglobin is below 3o<y c , double or treble 
the usual amount of blood should be used, the percentage obtained being 



EXAMINATION OF THE BLOOD — BLOOD CELLS. 



.385 



divided proportionately, (i). The examination should be made in a 
dark room, or by means of a light proof box and in any case some form 
of tube should be used for observation, a simple roll of black paper being 
ordinarily sufficient. 
Haemoglobin Estimation by Specific Gravity. — By the use of 
tables to be found in all the larger works 
dealing with this subject the haemoglobin 
present in a given specimen may be very 
accurately estimated by Hammerschlag's 
modification of Roy's method. The pro- 
cedure is too cumbersome and fussy to be 
recommended to the practitioner and will not 
be described. 

Oliver's Haemoglobinometer. — As shown 
by fig. 152 this instrument depends upon 
the scale of colors based upon diluted blood. 
Its use is sufficiently indicated by the dia- 
gram and it has no advantage over the two 
preceding methods. 

Gower's Haemoglobinometer. — This 
little instrument has the merit of extreme 
simplicity, yet in practice one may lose more 
time by its use than with the other more 
elaborate instruments, inasmuch as a slight 
error in dilution means a repetition of the 
whole process. 

Sahli's Haemoglobinometer.— This ad- 
mirable instrument resembles Gower's haem- 
ometer but is the best of all forms for accurate 
work. The empty graduated tube is filled to 
Fig. 153.— Sahli's haemoglobin- the mark io with a decinormal solution of 

ometer. 

HC1 which is saturated with chloroform. 

The blood is then added by means of a measuring pipette and the 
mixture made complete. Finally distilled water is added until the 
color corresponds to that of the control tube. 

The color comparison is remarkably easy and definite. 

The instrument should be kept in its case or in a dark place. 

THE ERYTHROCYTES AND THE LEUCOCYTES. 

The Red Blood Cell. Each cubic millimeter of human blood should 

2 5 




Unneces- 
sary. 



An excel- 
lent instru- 
ment. 



3 86 



MEDICAL DIAGNOSIS. 



Normal . 



Abnormal. 



Six 
varieties. 



How rec- 
ognized. 



Nucleus 

and 

granules. 



Disease 
association. 



contain from 4,500,000 to 5,000,000 erythrocytes, the former number 
representing the average for the female, the latter that of the male. 
A fluctuation of half a million cells may be assumed as within normal 
limits. The average size of these cells is 7.5^ but a wide variation is 
possible (6.5// to 8.5/i). Under pathological conditions one may 
meet with extremely large or extremely small cells, and with nucleated 
erythrocytes (erythroblasts) . 

Classification of Leucocytes. — The simplest modern classification 
deals with six varieties: — (1). The polymorphonuclear neuti • ophites 
which constitute from 60-75%. ( 2 )- The small lymphocytes (20-30%). 
(3). The large lymphocytes, and (4) the transitional forms (4-8%). 
(5). Eosinophiles (0.5-5%). (6)- Basophiles (0.5%). 

(1). The polymorphonuclear neutrophile cell measures 7.5-12/i and 
is characterized by its irregular, dark blue staining nuclei, often con- 
nected by chromatin strands, and the presence of neutrophilic granules, 
taking a lilac or pink color with Wright's stain. (2). The small 
lymphocyte. This contains a single round deep staining nucleus almost 
filling the cell and often obscuring the border of protoplasm. It 
measures 5-10^. (3). The large lymphocyte. This measures 10-15/* 
and carries a round or oval, pale blue staining nucleus and a relatively 
large amount of protoplasm. It differs from the transitional leucocyte 
only in its indented crescentic or reniform nucleus. (5). The eosin- 
ophiles (8-ii/j.) are readily recognized by their coarse, rose colored 
granules and polymorphonuclear type. (6). Basophiles. (7.5-12//.) 
The distinguishing feature of the basophile cell is its fine deep blue 
granules. The nucleus is polymorphous and stains a dull blue. The 
characteristic granules are best shown by Wright's stain and not at 
all by the triple stain. 

Unusual or Abnormal Forms. — The myelocytes. These leucocytes 
may contain either neutrophilic or eosinophilic granules constituting 
two sub -varieties. The nucleus is spherical or oval, tends to be eccen- 
tric, stains feebly with the blue, occasionally shows division and often 
shows a marginal light circle. The presence of the granules distinguishes 
it from the large mononuclear forms and the lack of lobulation or twisting 
of the nucleus from the polymorphonuclear cell. With Wright's stain the 
neutrophilic myelocytes show lilac or pink granules with a purplish 
admixture. Eosinophilic myelocytes show the ordinary eosinophilic 
granules. Significance. The cell is invariably pathologic, occurring 
in many cases of profound anaemia or excessive leucocytosis, occasionally 
in lymphatic leukaemia and Hodgkin's disease, but only in small numbers, 



PLATE II. 




I....I....I....I....I....I 



Chief varieties of cells encountered in health and disease (Wright's stain'. 1. Nor- 
mal red cell. 2. Common form of polymorphonuclear leucocyte. 3. Lesser lympho- 
cyte. 4. Eosinophilic myelocyte. 5. Eosinophilic leucocyte. 6-0. Neutrophilic leu- 
cocytes: upper left, transitional form, on right neutrophilic myelocytes. 7-7. Large 
lymphocytes. 8. Normoblast. 8. Normoblast showing division of nucleus. 0. Nor- 
moblast nucleus. 10-11. Basophilic leucocytes. 12. Nlegaloblast. 



3 88 



MEDICAL DIAGNOSIS. 



Giant 
" blast. 



Associated 
conditions. 



Meso- 
blasts. 



Ring 
bodies. 



Signifi- 
cance. 



Differen- 
tial value. 



of fine structure which stains a faint blue or green and in triple stain 
the specimen is surrounded by a white definitive ring. The nucleus 
is usually large, more rarely strikingly small and deeply staining like 
the normoblast or microblast. It represents defective hemogenesis and 
signifies degeneration, being found as a prevailing type oj erythroblasl 
only in primary pernicious ancemia, nitro-benzol poisoning, and bothrio- 
cephalus ancemia. In any severe anaemia an occasional cell of this type 
may be found. 

Microblast. — This cell (5-6/x) presents essentially the same appear- 
ance, aside from size, as the normoblast and has the same clinical sig- 
nificance. 

Unusual Forms. — Various mixed types are encountered (meso- 
blasts) which defy differentiation, showing contradictions in size and 
staining reaction; some which DaCosta regards as immature normo- 
blasts show a pale nucleus with acid stain 
stippling and polychromatophilic proto- 
plasm. Yet others, large in size, contain 
a small deeply basic staining nucleus and 
faintly stained protoplasm. These he 
would classify as megaloblasts. Cabot 
has described and drawn extraordinary 
intra and extra cellular ring bodies in lead 
poisoning, pernicious anaemia and lym- 
phatic leukaemia. They have also been 
found by DaCosta in the profound 
anaemias of sepsis. Basic ring bodies 
were previously described by Strauss and Rohnstein. It. is now 
known that these for the most part take the acid stain of Wright's 
solution, rarely the blue. 

Basophilic Erythrocytes.— May be encountered as fine, coarse, 
spicular or even ovoid granules occurring in regular or irregular dis- 
tribution and occurring in lead poisoning, chlorosis with intestinal 
auto-intoxication, practically all of the profound or pernicious forms 
of anaemia, but absent in the anaemia of renal and hepatic disease, the 
acute infections, syphilis and diabetes. 

The Blood Cell Count. — The differentiation with the various types 
of anaemia requires that the cells contained in 1 cm. of any given blood 
be directly and differentially counted and this is readily done with 
the modern apparatus. The Thoma-Zeiss hcemocytometer consists 
of two graduated capillar)' pipettes, i.e. the erythrocytometer and the 



go 



Fig. 154.— Basophilic stippling 
and Cabot's ring bodies. (After 
Cabot, Ewing and DaCosta.) 



EXAMINATION OF THE BLOOD — CELL COUNT. 



389 



leucocytometer for counting red and white cells respectively. The blood 
is drawn by suction or capillary attraction from the drop obtained by 
puncture, until it reaches the point marked 1, then rapidly wiped dry 
and the diluent quickly drawn in until it fills the bulb and reaches the 
mark 101.* While drawing in the diluent the pipette is revolved be- 
tween the finger and the thumb to set in motion the mixing bead 
contained in the bulb and when filled again thoroughly shaken and 
revolved for half a minute. This mixing should be repeated each time 
before expelling a drop for examination. One has then a mixture, 
each drop of which presents a blood dilution of 1:100. Many prefer 
a 1:200 dilution readily obtained by using the mark 0.5 as the upper 
limit for the indrawn blood. The blood rises quickly if the pipette is 

perfectly clean and may exceed the proper 
level if not watched or checked by with- 
drawing the point and quickly wiping it. 
If the higher dilution is used any excess 
is readily blown . out or better drawn 
down by touching the tip with filter 
paper or blotter. The next step consists 
in expelling the diluent occupying the 
capillary portion of the tube, after which 
a small drop of the mixture in the bulb 
is placed upon the central disc (shown 
in fig. 155), the cover -glass is placed in 
position and the cells given time to settle. 
The drop should just or very nearly fill 
the central plateau without running over 
into the moat around it when the cover- 
glass is applied, else the process must be repeated after thoroughly 
cleaning and drying the cover -glass and counting surface. At the 
point of contact between the cover-glass and the underlying plate con- 
centric color rings (Newton's rings) should appear indicating perfect 
contact. Their absence vitiates the count and indicates dust or moist- 
ure which must be removed and the process repeated. The specimen 
being placed under the microscope carrying a Leitz No. 6 objective and 
a No. 4 ocular or their approximate equivalents should show an even 

*The diluent used is Toisson's solution. Formula: — Methyl violet 5 B 

(0.025), Sodium chloride (1.0), sodium sulphate (8.o), neutral glycerine (30.0), 
distilled water (1O0.0). llayem's solution contains mereuiie chloride (0.25), 
sodium chloride (0.5), sodium sulphate (a.5), distilled water (iOO.o). 



Instru- 
ments and 
technique. 




Fig. 155. — Thoma-Zeiss blood 
counter, showing pipette, counting 
chamber and ruled field. 



Magni " c .1 • 
tion. 



39° 



MEDICAL DIAGNOSIS. 



Basis of 
method. 



Important 
precau- 
tion. 



Instru- 
ments and 
technique. 



Zappert's 
chamber. 



distribution of cells throughout both the ruled and unruled fields. There 
appears on examination a magnified ruled field with squares appearing 
as in fig. 155. Up to this point a certain amount of blood diluted 100 
times has been placed upon a field so ruled that each of its squares 
represents an area of 1-20X1-20 mm. i.e. each side of the square repre- 
sents 1-20 mm. A third dimension has been added by the cover-glass 
brought into contact with the blood but lying 1-10 of a mm. above the 
level of the depressed central disc which carries the squares upon its 
surface. One has now to count the number of cells lying within a 
definite number of the small squares, and for the sake of accuracy 
it is best to include the whole 400 though for ordinary work a less 
number may be taken if the blood seems to be perfectly distributed.* 
One should pursue a systematic course crossing from left to right 
and back from right to left and so on, counting not only the cells 
that He within each square but those that touch its upper and left 
hand sides. Having counted the cells, say in 100 squares, one mul- 
tiples by 4000 if the original dilution was 1:100 and by 8000 if it 
were r:2oo, the result representing the number of cells in 1 cm. of 
the blood under examination. f The blood counter must in every 
case be cleaned immediately after using, (1st) wtith water, (2d) alco- 
hol, (3d) with ether, and the glass bulb should be absolutely free 
and movable after the process is completed. If to be again used at 
once, air should be blown through the tube by means of a hand bulb 
and rubber tube, not the mouth. The counting chamber should be 
cleaned with cold water only and should not be exposed to direct sun- 
light for fear of softening the cement. 

The Leucocyte Count. — For this the large calibred pipette is used 
with a diluent consisting of an aqueous solution of glacial acetic acid 
(0.5%) which leaves visible only the white cells. The most accurate counts 
are made by using 0.5 rather than 1 as the basis of the dilution, and 
even this requires a good sized drop. Furthermore, the pipette must be 
kept nearly horizontal at the time and after the diluent is added, else it 
will run out of the tube. The diluent is then added to the point n and 
the count can be made with the erythrocyte counting chamber or better 
with Zappert's chamber in which the central square {one millimeter) is 

* For the highest degrees of accuracy the whole process is repeated several 
times and an average taken, but this is ordinarily impossible in clinical work. 

t Assuming that 1200 erythrocytes have been counted in 100 squares in 1 
square there are 12 cells. This is multiplied by the dilution, i.e. 100 or 200, 
and by 4000 because the microscopic squares represent but 40V0 °f t ^ ie 
cubic mm. used as the standard. 



EXAMINATION OF THE BLOOD. 



39 1 



surrounded by 8 unruled squares oj the same size. The total obtained 
by counting the leucocytes in the 9 squares is multiplied by 200 and 
divided by 9, assuming a dilution of 1:20 as above described. If the 
ordinary counting chamber is used the process is greatly facilitated by 
inserting an eye piece diaphragm into the tube of the ocular which will 
cut off exactly 100 of the small squares. These may be bought or can 
be made by the physician from metal or cardboard by the physician. 
The leucocytes in 400 small squares of the erythrocyte chamber may 
then be rapidly counted and as many additional outside diaphragm 
fields as are necessary to correct work. Accurate white blood counts 
require patience and the counting of a large number of fields, for a 
slight error has a disastrous effect. * Usually 
two drops of the 1-10 or four drops of the 1-20 
dilution will enable one to count 140-150 cells. 

Oliver's Haemocytometer. — This ingenious 
instrument is shown in fig. 156, and, save in cases 
where the white count is desirable or in leukaemia 
where the excess of leucocytes vitiates any optical 
method, is convenient and accurate. Method. A 
small amount of Hayem's solution is placed in the 
glass tube and into it is stirred the blood taken up 
by the capillary pipette. It is then diluted gradu- 
ally with the Hayem's mixture until a bright hori- 
zontal line becomes visible as the observer looks 
hll&g'&Ws h°ima! thr ° u S h the mix ^ at a candle flame beyond, 
tocytometer. Each point on the scale represents 50,000 red cells. 

Precautions.— (a). One looks at the edge of the tube, not its flat 
faces, (b). The pipette should be thoroughly clean before using, 
(c). The tube should be inverted to secure proper admixture each time 
that the diluent is added, (d). An imperfect marginal line forecasts 
the appearance of the complete transverse line and warns one to go 
slowly with the dilution, (e). A small Christmas candle should be 
used in a dark room. (f). The tube should be close to the eye and the 
observer fully ten feet from the candle, f 

The Haematocrit.— (Hedin-Daland). This consists of a graduated 
capillary tube, each degree of which represents 100,000 erythrocytes. 

*Thc ingenious self-filling and self measuring pipette of Durham has 
many advantages, but requires separate mixing vessels. 

t Cabot finds the instrument highly inaccurate in sever* anemia and 
unavailable in leukcemia but otherwise it is an excellent instrument for 
erythrocyte determination, 



1 jgp 

1 —""> 

1 ~ 60 

1 ^ 
1 ^ Zo 




1 



Basis of 
count. 



Use of ery- 
throcyte 
counter. 



Drops 
required. 



Ingenious 
and con- 
venient. 



Technique. 



392 



MEDICAL DIAGNOSIS. 



Approxim- 
ate results. 



The tube is filled with blood and placed (with a similar tube opposite) 
in the centrifuge which should be revolved at high speed for at least two 
minutes when the red column will represent the erythrocytes present 
as indicated by the scale. The tube when filled by suction is dried 
and closed at its other end by the vaseline coated finger which is kept 
in place while the rubber suction tube is withdrawn, and results obtained 
are rapid but probably only approximate. 

Differential Counting. — This involves the examination of from 
500 to 800 leucocytes and a determination of the exact number of each 
variety present. The field should be systematically and carefully gone 
over, and if ordinary care is observed, the procedure offers no difficulty 
for one who is sufficiently skilled to recognize the various types of 
white cells and the abnormal erythrocytes which should be included 
in any such procedure. The process is a tedious one involving as a 



Laborious 

but 

valuable. 



Digestive. 



Preagonal. 



Pregnancy. 



Newborn 
babes. 



rule the counting of 2 or 3 entire stained smears. 

LEUCOCYTOSIS AND LYMPHOCYTOSIS.— Assuming that the 
term leucocytosis covers an increase of the polymorphonuclear neutro- 
philic cells both relative and absolute, it is evident that one must know 
first what constitutes a normal leucocyte count; second, what conditions 
other than disease may increase the number. The Normal Average. 
This varies from 5-10,000 to the c.mm. of peripheral blood, the average 
being 7500. Physiologic Leucocytosis. — The most important is the 
so-called digestive leucocytosis which represents on the average an 
increase over normal of about ^. The variation is greater after a 
heavy proteid meal than on a vegetable diet and reaches its maximum 
usually within from 2 to 4 hours after a meal. The increase may be 
purely polymorphonuclear or more rarely is common to all normal forms. 
It may be delayed in cases of subacid dyspepsia and is very marked in 
nursing infants and diabetics. The so-called preagonal leucocytosis 
may be observed immediately before death, the counts occasionally 
reaching 20,000 or even 30,000 cells. Cabot states that in pernicious 
anaemia this may take the form of so decided a lymphocyte increase 
as to simulate lymphatic leukaemia, nevertheless as a rule it is a poly- 
morphonuclear increase due probably to the stasis of a failing circulation. 
It is important to remember that both the later months of pregnancy in 
primiparae and the first week following delivery a moderate leucocy- 
tosis is the rule. So also in newborn babes the count usually ranges 
from 50-20,000 during the first two days of life and that after the second 
week during the first year it remains at 10-15,000 per c.mm. The 
type of physiologic leucocytosis is almost invariably polymorphonuclear 



LEUCOCYTOSIS OF DISEASE. 



393 



General 
conclu- 
sions. 



(85 to 90%) though there may be a coincident lymphocyte increase in 
the newborn, malignant disease, or in hemorrhage. 

The Leucocytosis of Disease. — So many diseases are associated 
with a more or less marked leucocytosis that it is only necessary to 
enumerate some of the more striking instances and more useful to 
remember the exceptions or more particularly the cases in which a dimi- 
nution (hypo-leucocytosis) occurs. Practically all inflammations, par- 
ticularly of serous membrane, and any suppurative process attended by 
toxaemia would ordinarily produce leucocytosis, yet we may have 
these, lacking such a phenomena because (a) the inflammation or toxcemia 
may be too slight to excite a reactive change, (b) because the toxin over- 
whelms the organsim, thus preventing leucocytic reaction, (c) because 
the organism is primarily too feeble to respond. In illustration one may 
cite lobar pneumonia as representing a disease in which leucocytosis 
is ordinarily marked, and typhoid fever in which a leukopenia is ordi- 
narily found. These diseases stand at opposite poles, the one being Examples 
sthenic and the other asthenic, the one of brief duration, the other 
prolonged and tedious, the one showing early and profound toxaemia, 
the other allowing its victim to escape by resolution before the system 
is overwhelmed by toxins. Acute appendicitis offers another illustration. 
In this disease one may have an inflammation and toxaemia so slight 
as to produce no leucocytosis, and overwhelming toxaemia with the same 
result, or, as is the rule, a well defined leucocytic reaction representing 
"good vitality opposed to sharp infection. It is useless to attempt to 
name or even tabulate the conditions giving rise to leucocytosis. In abscess 
it is practically constant, but in malignant disease a high count may be 
found only in rapidly growing tumors of the kidney, lungs or liver, 
and in the author's experience especially in metastatic hepatic inva- 
sion from gastric carcinoma. In ptomaine poisoning, urcemia,chohemia, 
and gas poisoning the leucocytosis may be marked. So also in cases 
of acute delirium, convulsions, after surgical operations or indeed after 
general anaesthesia. The blood findings of the various diseases are dis- 
cussed under the individual headings. 

Leucopaenia. — (Hypoleucocytosis). This covers any leucocyte count 
running below 5000 cells, excluding of course those cases of reduction 
associated with profound anaemia. As might be expected this condition 
may be present as a result of malnutrition or starvation, but iis chief 
importance is its occurrence in certain diseases of the infectious and 
toxasmic type. Amongst those are typhoid, paratyphoid, malaria, Malta 
fever, influenza, measles and rotlnln, tuberculosis (in the absence oi sep- 



Various 

associated 

conditions. 



:l.ch!> 

mportant. 



394 



MEDICAL DIAGNOSIS. 



Normal of 
infancy. 



Abnormal. 



Syphilis. 



tic symptoms), leprosy, trypanosomiasis and less commonly in chlorosis, 
chronic infantile gastro-enteritis, and, following the use of agaricin, 
atropin, camphoric acid, ergot, picrotoxin, sidphonal and tannic acid. 

Lymphocytosis. — This may be either relative or absolute, the former 
without any necessary increase in the total white cell count, the latter 
covering both an increase in percentage and in the total lymphocytes. 
The latter is practically always a lymphatic leukcemia. It should be 
remembered in this connection that in infancy the lymphocytes and 
transitional cells may constitute 55 or 60% of the total white cells, gradu- 
ally dropping to the normal figure at the age of 4 or 5 with a correspond- 
ing increase in the polymorphonuclear forms, hence the average increase 
percentage (50-70) has little significance at early ages. Either the 
large, small or transitional forms may predominate in any case and the 
condition is invariably pathologic when occurring in older children or in 
adults, and is usually associated with profound malnutrition, and appre- 
cially marked in the terminal stages of diseases of that type as well as 
in marked anaemia, and in several of the acute and chronic infections 
characterized by hypoleucocytosis, notably malaria, typhoid, Malta 
fever, scarlet fever, diphtheria, measles, tuberculosis and trypanosomiasis. 
So also we find the condition marked in ailments involving the lymphatic 
glands or spleen, or the invasion of lymph channels by malignant growths. 
As regards drugs it is said to follow the administration of thyroid, 
tuberculin, quinine and pilocarpin. Its constancy in syphilis in which 
it is combined with eosinophilia is of diagnostic importance. 

Eosinophilia. — The determination of this condition is made by a 
differential count establishing their proportion associated with a count 
of the total leucocytes, the latter multipled by the former giving the total 
number of eosinophiles in a c.mm. It is of lessened value as a clinical 
sign because present in a great number of diseases but its constancy in 
trichiniasis, hydatid disease and in the presence of the more important 
intestinal parasites is of some value. The attempt made by some of the 
foreign haematologists to create a group of which eosinophilia should be 
diagnostic has not proven successful. It is, as stated, of clinical value 
in syphilis when combined with lymphocytosis. 

Melanaemia. — Pigmented leucocytes occur in cases of melanotic 
sarcoma and in malaria, free in the blood only during the segmentation 
stage of the latter disease. 

Iodophilia. — If a dry but unfixed smear be gently pressed down upon 
a generous drop of specially prepared iodine and potassic iodide solution* 

* Iodine 1. Potassium Iodide 3. Water 100. Gum Arabic 50. 



AGGLUTINATION REACTION. 



395 



Other 

diseases. 



the normal blood cells take a uniform yellow tint but in septic condi' 
tions both intra and extra cellular brown granules are seen or a diffuse Sepsis 
protoplasmic staining occurs, especially affecting the neutrophilic 
leucocytes and, rarely, the basophiles and myelocytes. 

The reaction is reasonably constant in septic conditions other than 
pure tuberculous abscesses, but is present in many other diseases, such 
as purpura haemorrhagica, acute miliary tuberculosis, certain typhoids 
and malignant disease. It is of genuine value in the differentiation 
of septic from non septic effusions and joint disease. 

Perinuclear Basophilia. — Neusser's perinuclear basophilic granules 
occurring in specimens submitted to the triacid stain are by him regarded 
as indicating the uric acid diathesis but are generally regarded as 
accidental products of no diagnostic significance. 

Agglutination Reaction. — Our present understanding of the phe- 
nomena constituting the so-called agglutination reaction which have 
proven so valuable in the diagnosis of certain obscure diseases depends 
upon the known fact that if erythrocytes or other cells not those of the 
animal into whose blood they have been introduced, or bacteria similarly Basis, 
injected, produce in the blood serum of the animal so treated the peculiar 
quality of agglutinating and precipitating, in vitro, the foreign elements. 
This involves the assumption of agglutinins and precipitins as products 
evolved during adaptation or immunization. The process has proven Value 
of value in a number of diseases and is best illustrated by typhoid fever 
in which disease is found its first clinical use through the work of Widal 
based upon the previous investigations of Pfeiffer, who worked along 
purely bacteriological lines seeking to apply the phenomena to the 
identification of bacteria. The agglutination reaction of typhoid, 
paratyphoid, colon infections, dysentery, cholera, plague, Malta fever 
and to a much less degree of pneumonia and tuberculosis have proven 
valuable. An early and definite reaction is chiefly marked in typhoid, 
Malta fever and cholera. In paratyphoid one is sometimes embar- 
rassed because of the fact that the paratyphoid bacilli of different 
epidemics may not react. In dysentery there are three types of bacilli 
to be dealt with, viz.: — those of Flexner, Shiga and Hiss, while in plague 
the reaction is not constant and occurs too late to be of use, and the 
same objection of inconstancy applies to tuberculosis and pneumonia.* 

* The student is earnestly advised to read in this connection a description 
of Ehrlich's side-chain theory of immunitv, an excellent description of 
which may be found in DaCosta's book, Clinical Hematology, 1005," 
page 151. 



I diseases 
yielding 

reactions. 



I onfusing 
(actors. 



39 6 



MEDICAL DIAGNOSIS. 



.Limited 
value. 



Technique. 



Counting the Blood Plates. — This requires a diluting fluid* through 
a drop of which placed upon the finger the puncture is made. After 
mixing, the count is made by the Thoma-Zeiss counting chamber to 
determinate the ratio of plaques to erythrocytes. It is then only nec- 
essary to count the erythrocytes to know the number of plaques present 
in the given specimen. 

Coagulation Time. — It is sometimes important to estimate the 
coagulation period in haemophilia, purpura and in "obstruction of 
the biliary 7 tract with or without jaundice" (Cabot) as in 
these conditions clot formation may be greatly retarded. 
Wright's capillary' tubes may be used or the simple 
method represented by fig. 157. In the former coagula- 
tion should occur within from 3-6 minutes, by the simpler 
method from 2^-5 . The latter merely involves the plac- 
ing of several drops of the suspected blood upon slightly 
warmed microscopic slides which are tilted upwards at 
varying intervals until they appear as in B of the plate, the 
elapsed time representing the coagulation period. 

The Determination of Alkalinity. — Some personal 
experience with this method has convinced the author that 
it does not merit attention as a clinical procedure. 






1 



Fig. 157. 
Delayed co- 
agulation of 

Miscellaneous Methods of Blood Examination. — pietestf(After 

estimation of erythrocytic BaCosta ^ 



Ingenious methods for the estimation of 
vulnerability, determination of the total blood volume, of fat and fatty 
of iron viscosity, etc., are interesting but are 



acids, of osmotic tension, 

not available, and, for the most part, not important for the general 

practitioner. 

CYTODIAGNOSIS— Widal has given this name to the study of 
the leucocyte content of pleural, peritoneal and cerebro -spinal fluids 
as they are obtained in operative or diagnostic aspiration. It is a 
valuable procedure within narrow limits. The fluid must be centrif- 
ugalized, and if immediate attention cannot be given it, any clot may 
be broken up by shaking in a flask w T ith small glass beads or the 
fluid may be drawn into a syringe or aspirator flask half full of a 
solution consisting of calcium oxalate (2 parts) and normal saline 
solution (1000 parts. Salhi). From 10 to 20 c.c. should be obtained 
if possible, the centrifuge must be run from 5 to 10 minutes accord- 
ing to the speed obtainable and the fluid kept on ice and examined 

*Aqueous solution of sodium chloride 1 % and potassium bichromate 5 % 
(Determann). 



EXAMINATION OF THE RLOOI) JNOSf'OI'Y. 



397 



within 24 hours. Examinations are best made by staining smear prep- 
arations as in the case of the blood. The triacid stain is satisfactory 
or Wright's stain may be used to save heating the specimens, though 
its methylene blue may over -stain in the sharply alkaline serum. Under 
the microscope we consider erythrocytes, endothelium and tumor cells 
as well as leucocytes and the following reasonably dependable conclu- 
sions may be drawn, (a). The presence of large amounts of blood 
suggests carcinoma, tuberculosis, and the hemorrhagic diseases, but may 
be present in cardiac and nephritic cases, though usually accidental, 
(b). In general the predominance 0} polymorphonuclear forms indi 
cates marked and relatively recent inflammation, (c). A large number 
of mononuclear cells indicates a less acute process, its later or chronic 
stages, or, the chronic stage of a non-specific exudate, (d). A large 
number of endothelial cells unassociated with any considerable number of 
leucocytes speaks for a transudate, (e). Specific tumor cells may if 
typically grouped prove a malignant growth, but ordinarily can with 
no certainty be distinguished from single or grouped endothelial cells. 

Primary Tuberculosis is indicated by a predominance of lympho- 
cytes after a week or ten days; acute infection, by polymorphonuclear 
preponderance. Predominance of endothelial cells in tesselate arrange- 
ment indicates a transudate. Secondary tuberculous pleurisies show 
polymorphonuclear predominance or a sediment of necrotic cells and 
debris. An exudate showing bacteria and 90% or more of polymor- 
phonuclears means that empyema is imminent (Musgrave) * 

INOSCOPY.— Jossuet's method of predigesting the coagulum of 
suspected exudates as preliminary to the examination for tubercle 
bacilli has proven of much value in pleuritic cases. Its findings have 
less accuracy, however, than animal inoculation and possibly than 
cytodiagnosis, so that it is the positive factor that should be consid- 
ered, the failure of the test being no adequate proof of the absence of 
tuberculosis. 

Technique. — The fluid is collected in sterilized flasks and the clot 
when formed, thoroughly washed on sterile gauze spread over the 
mouth of a funnel or receptacle. The clot is then placed in a flask or 
flasks in each of which is poured from 20-30 c.c. of the solution (pepsin 
2 gms., glycerin and strong IIC1 of each 10 c.c sodium fluoride 3 gms., 

* Musgraw highly recommends Wright's stain, 3 parts, methyl alcohol, 

1 part. Stain jo to 15 minutes, treat with S or 10 drops of water, lot it 
stand 2 or 3 minutes and wash gently by flooding with water several times. 
allowing it to stand a lew soeonds with eaeh washing. 



Diagnostic 
inferences. 



Useful, 
certain. 



398 



MEDICAL DIAGNOSIS. 



Haemoglo 
bin-ery- 
throcyte 
ratio. 



distilled water 2000). Digestion will be complete in about two or 
three hours at body temperature. Centrifugalization of the mixture 
for 10 minutes is followed by decantation and the staining of cover-slip 
preparations to which a bit of egg albumin may be added. Gabbett's 
method and stain should be used but the preparation must not be as 
vigorously decolorized as is usual in sputum mounts; 30 to 45 seconds 
being sufficient. 

DISEASES OF THE BLOOD. 

The Ancemias. 

Types of Anaemia. — There are three principal types of anaemia, 
(1) simple ancemia or chlorosis, (2) secondary ancemia, which as its name 
implies is that which follows or is associated with other diseases. 
(3). Pernicious ancemia. In general one may say that chlorosis 

j is characterized by a predominant haemoglobin loss and a relatively 
slight diminution in the number of red cells present. That is to say 

i the individual cell is poor in haemoglobin. Secondary ancemia shows 
as a rule a more even reduction in both elements. Pernicious ancemia 
is the exact reverse of simple anaemia in that the cell decrease predomi- 
nates and therefore the haemoglobin value of the individual cell is 
high. (See Figs. 149, 158.) 

General Considerations. — Color. — In the anaemias pallor as affect- 
ing the skin and mucous membranes is the rule, but is subject to fre- 
quent exceptions. Persons may be pale, yet not ancemic, or ruddy and 
profoundly ancemic. The author recalls two cases of advanced leukaemia 
in which the color was most deceptive. The student and the indoor 
worker is often pallid, yet not anaemic. The outward signs of anaemia 
should be sought for in the face, the conjunctiva, the lips, the mucous 
membrane, the lobes of the ear, the ringer nails, tongue and pharynx. 
In chlorosis there is usually marked pallor and the skin is likely to show 

I a greenish yellow tint. In pernicious ancemia there is ordinarily very 
marked pallor and the skin is of a lemon yellow tint. In secondary 
Variations, ancemia aside from pallor one meets with many variations in color. 
In acute Bright' s disease the skin may be of a pasty white, or 
show a peculiar sallowness, brown or fawn color, more or less char- 
acteristic of the advanced chronic parenchymatous or "mixed" type 
of the disease. Interstitial nephritis, often yields no such evidence, 
being found in men of normal complexion, or in those who have 
the ruddy countenance of the high liver. Syphilis. Certain cases 
of congenital and tertiary syphilis show a peculiar sallowness 



Mislead- 
ing. 



DISEASES OF THE BLOOD — AN/EMIA. 



399 



impossible to describe, but easily recognized by those who have 
been shown it. Malignant disease especially carcinoma of the stomach 
is often associated with a somewhat characteristic earthy pallor. In 
diseases of the mitral valve one frequently finds anaemia masked by 
color due to chronic congestion. 










Fig. [58. 



Muscular Weakness.— In all pronounced anaemias one moots with 
lassitude and muscular weakness, varying as a rule with the severity 
of the disease. It is least marked in mild ansemias o\ the secondary 
type and most evident in pernicious anaemia. Temperature. Three- 






Bruit de 

Diable. 



Pseudo- 
Corrigan 
pulse. 

Capillary 
pulse. 



Anaemic 
neurasthe- 
nia. 



400 



MEDICAL DIAGNOSIS. 



fourths of all cases of pernicious anaemia are accompanied by tempera- 
ture, usually of the intermittent type, with an evening exacerbation. 
It is by no means an infrequent symptom in severe cases of chlorosis* 
or secondary anaemia. 

Gastro-intestinal Disturbances. — Symptoms referable to disturbed 
digestion, gastric or intestinal, are encountered chiefly in the chlorotic 
and pernicious forms of anaemia and in the leukaemias. Anorexia, 
bulimia, nausea, vomiting, constipation and diarrhoea are the common 
symptoms. Established and advanced pernicious ancemia is usually 
associated with exhausting attacks of diarrhoea and intercurrent vomiting. 

Respiratory System. — Dyspnoea is more or less pronounced in all 
severe anaemias, but particularly so in marked chlorosis and perni- 
cious anaemia. 

Circulatory System. — Palpitation, syncope and precordial oppression 
are common. Edema of the extremities is not infrequent in chlorosis 
and is invariably present in advanced leukaemia and pernicious anaemia. 
The pulse is usually of low tension, a curious humming sound is heard 
in the vessels of the neck, and various murmurs are heard over the heart 
and the great vessels. 

Anaemic Murmurs. — The general characteristics of the murmurs 
of anaemia are: — (a). Their systolic time. (b). Softness of quality, (c). 
Predilection for the pulmonary area. (d). Absence of marked and 
sequential cardiac outline changes, (e). Tendency to disappear as ancemia 
is improved by treatment. 

These murmurs may be heard over any of the valvular areas, but are 
most frequent in the pulmonary and mitral regions. A systolic murmur 
in the subclavian and carotid is a very common feature. In certain 
cases where ancemia and neurasthenia are combined one may find out- 
ward symptoms suggesting aortic regurgitation viz.: — throbbing periph- 
eral vessels, water hammer pulse, and even a capillary pulse. This 
condition need not mislead one in the absence of a diastolic murmur, f 
and a modified aortic second sound. 

Nervous System. — The symptoms under this head are many and 
various. Insomnia, drowsiness, vertigo, mental dulness and apathy, 
extreme irritability, perverted sensation, neuralgia, neurasthenia, hysteria, 



* It nevertheless should always suggest tuberculosis in these cases and 
hence a thorough examination of the lungs. 

f The author has reported one (terminal stage) case of pernicious anaemia 
in which all these symptoms were present without aortic valve changes ade- 
quate to explain the murmur, and a few other such clinical curiosities are 
to be found in the literature. 



> 



DISEASES OF THE BLOOD — ANEMIA. 



40I 



headache, and even delirium may be encountered though delirium is not 
often seen save in pernicious anaemia or the last stage of leukaemia. 
Headache may be found in all degrees of severity in simple cases of chlorosis 
and one form is peculiarly interesting by reason of its close resemblance 
to the headache of meningitis.* Such headaches are so severe as to 
require most radical measures for their relief, and often tend to recur 
until the general therapeutic indication, namely, the administration 
of iron, is fulfilled. 

General Nutrition. — In simple ancemia the fat is usually well pre- 
served, giving the patient a plump appearance. In secondary anemia 
the state of nutrition is dependent upon the primary lesion. In pernicious 
ancemia even in its later stage there is often an appearance of good nutri- 
tion, due to the presence of overlying fat, but the skin in these cases has 
a peculiar velvety feel, and the muscles are of the consistency of jelly to 
the touch. 

The Eye. — Muscular insufficiencies are common, retinal hemorrhage 
frequently occurs in pernicious ancemia and in all severe forms the 
ophthalmoscope shows a pale fundus. 

General Etiologic Factors. — Age. Secondary and pernicious ance- 
mia occur for the most part in those at or above middle age. Chlorosis 
is essentially a disease of the earlier years, most often commencing 
at or about the age of puberty. Sex. 90% of all cases of chlorosis 
(simple anaemia) occur in young women. Pernicious ancemia is more 
frequent in the male, secondary ancemia follows the laws of incidence 
of the primary lesion. 

Causes of Anaemia. — Little is positively known of the pathogenesis 
of anaemia and the scope and purpose of this volume forbids a discussion 
of the theories. General Causes. In connection with simple anaemia, 
one is likely to find defects in food, environment, habits and general 
sanitation. Boarding-school girls and working girls may suffer alike 
from insufficient or improperly prepared food, or from lack of variety, 
no less than from poor ventilation, overwork, or lack of fresh air or 
sunshine. Depressing emotions, such as grief, home-sickness or disap- 
pointment in love often play their part, and the effect of all of these 
general factors is shown in Arctic explorers who have in many 
instances suffered from severe forms of anaemia during the Arctic 
night, when nostalgia, darkness, fatigue, poor ventilation ami improper 
diet were all present. 



*Two cases have come under th 
diagnosis of cerebral meningitis had r 
26 



uthoi- 
ltcd fi 



notice in which a mistaken 
>m this curious condition. 



Mislead- 
ing head- 
ache. 



Varies with 
type of 
anaemia. 



Pale disc. 



Bad hy- 
giene. 



I .ovesick- 
ness and 
nostalgia. 



402 



MEDICAL DIAGNOSIS. 



Etiologic 
factors. 



Achromia 
marked. 



Unknown 
causation. 



Secondary Anaemia. — This may be associated with the follow- 
ing conditions: — (a). Repealed hemorrhages (hemorrhoids, nose bleed, 
uterine hemorrhage, gastric ulcer, hepatic cirrhosis), (b). Malignant 
disease, especially carcinoma of the stomach, (c). Syphilis, leprosy 
and tuberculosis, (d). Mineral poisoning, arsenic and lead especially, 
(e). Malaria, (f). Bright' s disease in its various forms, (g). Intestinal 
parasites, (h). Auto-intoxication, (i). Any acute infectious disease, 
acute rheumatism being the chief. 

The foregoing statements as to general symptomatology are applicable 
to all forms of ancemia in varying degree. Considered as arbitrary 
types, chlorosis stands at one pole, pernicious ancemia at the opposite, 
while secondary an&mias are ordinarily overshadowed and dominated by 
the symptoms of the causal lesion and may assume varying and at times 
misleading forms. 

CARDINAL SYMPTOMS OF THE ANEMIAS.— Chlorosis.— 
Age. Young adults. Sex. Female in most instances. Color. Simple 
pallor or a "greenish yellow." 

General symptoms as described in the preceding pages usually 
moderate in degree. See page 398. 

Blood Findings. — The color index is low* the haemoglobin running 
from 12 to 75%, its average being about 45%. Red cells are not pro- 
portionately decreased, the average being 4,000,000 per c.cm., a count 
under 2,000,000 rare and the average size of the cell less than normal: 
Stained specimens show marked achromia and old cases show marked 
variation in the size of the cells, but cell deformity, i.e. poikilocytosis, 
is rare. Nucleated red cells are seldom found and when present are 
normoblasts. The leucocytes are normal or slightly decreased and 
relative lymphocytosis is common. Myelocytes are rarely found and 
the eosinophiles are decreased. The coagulation period is short. The 
patients appear as a rule, plump and well nourished though pale, and 
their occupation is likely to be that of laundress, shopgirl, factory worker 
or school girl. The developmental period is the one of commonest inci- 
dence. 

Pathogenesis of Chlorosis. — Practically nothing is known of the 
pathogenesis of this disease. It is commonly associated with con- 
stipation and gastro-intestinal derangement, and has given rise to the 
theory of auto-intoxication. Arterial hypoplasia has its advocates, and 
it has even been supposed to represent an incipient tuberculosis. No 
one of these theories can be accepted, entire, at the present time. The 

* For definition of color index^see p. 378. 



DISEASES OF THE BLOOD— PERNICIOUS ANEMIA. 



403 



therapeutic test for chlorosis is found in the prompt response of its symp- 
toms to the proper administration of iron. 

PERNICIOUS ANEMIA.— Age. Usually middle age. Sex. Males 
chiefly. Therapeutic Test. Iron fails absolutely. Color. Lemon yel- 
low in most instances. Nutrition. External fat may be preserved until 
late, but tissues are flabby and gelatinous in feel. 

Etiology and Pathogenesis. — Unknown. May be due to A mystery, 
excessive haemolysis or to deficient haemogenesis. It follows, 
oftentimes, shock, mental strain, prolonged exposure and fatigue, 
syphilis, malaria, alcoholism, and in women repeated and excessive 
childbearing, but any or all of these factors seem to be only con- 
tributory. 

Symptoms. — As described under general symptomatology (p. 401), 
but presenting a most extreme type of muscular weakness, impaired 
nutrition, gastro-intestinal disturbance, vertigo, subcutaneous, mucous 
membrane, and retinal hemorrhage and slight edema of the extremi- 
ties. The aesthenia is progressive, yet temporary recovery is common 
and may endure for several years though the ultimate prognosis is 
fatal. 

Blood Findings. — The blood is pale and slips quickly off the ear 
or finger following puncture. The color index is high and the red High color 

11 j , , index, and 

cells are reduced on the average to 1,500,000 per can., 1,000,000 low eryth- 
being a common finding. The hcemoglobin may be as low as 15% but 
in most instances is relatively in excess. The coagulation period is 
prolonged, the average diameter of the red cell is increased, poikilocy- 
tosis or cell deformity is marked, the cells show great variation in size 
and nucleated red cells are invariably present though often found only 
after careful search and only rarely in great numbers. The megalo- 
blasts must be found to outnumber the normoblasts or a positive diag- 
nosis is not justified. An excess of microblasts or of normoblasts 
usually indicates a severe secondary anaemia. PolycJiromatophilia, i.e. 
irregularity in staining and consequent lack of uniform color in cer- 
tain cells is a marked characteristic of this disease. The leucocytes 
are diminished in f of all cases and this leukopaenia may be extreme. 
the average being less than $ the normal count. Myelocytes are 
nearly always present though in small numbers. It is usually possi- 
ble to make an accurate diagnosis of pernicious anaemia by the Mood 
findings alone but now and then cases occur in which the clinical 
history and physical signs must be invoked. Bothriocephalus infection 
and nitro-benzol poisoning present an almost identical picture. Advanced 



rocyte 
count. 



Predomi- 
nance of 
megalo- 
blasts. 



404 



MEDICAL DIAGNOSIS. 



Only a 

syndrome. 



Essentially 
chronic. 



cases of malignant disease of the stomach may present quite as extreme 
an anaemia, but in this the small cell type usually predominates, both as 
to nucleated and non-nucleated cells. 

SPLENIC ANAEMIA.— This condition has not yet made itself a 
place in medicine as a clinical entity and its features do not seem to be 
sufficiently characteristic to constitute a separate disease. Anaemia 
with splenic enlargement would seem to be the more correct term. 
The one constant blood finding is leukopenia, the average leucocyte 
count being about 50% normal. So far as haemoglobin and erythro- 
cytes are concerned any form of anaemia may be simulated, the marked 
secondary type being that commonly shown. We must regard the con- 
dition for the present as an interesting symptom-complex, lacking the 
glandular enlargement of Hodgkirts disease and the peculiar blood 
changes of leukaemia, and adding to the ordinary symptoms of anaemia 
that of splenic hypertrophy, commonly associated with hepatic enlarge- 
ment. A large number of these 'cases prove to be malignant growths 
on autopsy. 

LEUKEMIA.— (White blood). Historic Note. Until 1841, this 
disease was regarded as a purulent inflammation of the blood. John 
Hughes Bennett and Virchow gave the first accurate account of the 
disease. 

Pathogenesis. — Leukaemia is undoubtedly a primary affection of the 
bone marrow and the lymphoid structures, the essential change being 
one of myelocytic or lymphocytic hyperplasia, leading to deficient red 
cell production. 

Varieties. — These are two forms of leukaemia, (a). Spleno-medul- 
lary. (b). Lymphatic. In the first form the blood assumes the so- 
called myeloid type, in the second, the lymphoid. Although several 
cases of acute myelogenous leukaemia have been reported, we may 
for the present regard it as essentially a chronic disease. Lymphatic 
leukaemia on the other hand may be either acute, subacute or 
chronic. 

SPLENO-MEDULLARY LEUKEMIA.— Etiology.— Age. May 
occur at any age, but chiefly in middle age. Sex. Males for the 
most part. Other etiologic factors are not well understood. 

Symptoms. — The disease is not likely to be detected until well 
advanced, and the general symptoms are then those of a profound 
anaemia with an especial tendency to hemorrhage and serous effu- 
sions. Dyspnoea is marked, loss of weight is usually extreme and 
both liver and spleen are enlarged, the latter to an enormous degree 



DISEASES OF THE BLOOD — LEUKAEMIA. 



405 



in certain cases, and always to a marked degree.* It is astonishing Insidious 
that so great an enlargement may be unattended by serious discom- i ment. 
fort, but such is oftentimes the case. 

Blood Findings. — The red cells are markedly reduced and the 
white cells are greatly increased in number, the average count being 
400,000, and the maximum frequently exceeding 1,000,000 cells. The 
characteristic white cell of leukaemia is the myelocyte and from 20% 
to 50% of the leucocytes present are of the myelocytic type (see j 
plate II. The eosinophiles are also present in unusual numbers ; 




Fig. 159.— Lower section shows a lymphatic leuka?mia. Upper section normal 
blood showing leucocytosis. The types of cells should be carefully noted. 

showing both an actual and relative increase. Both the lymphocytes 
and polymorphonuclear cells though absolutely increased arc relatively 
diminished. Megaloblasts, normoblasts and microblasts are present in 
quantity and their nuclei frequently show mitotic changes. One <>/ 
the most striking though not invariable symptoms of the later stages 

* In one case shown by the author to the Minnesota State Medical So- 
ciety in 1903, the splenic margin actually touched the anterior superior 

spine of the right side. 



406 



MEDICAL DIAGNOSIS. 



Hemorrha- 
gic ten- 
dency. 



Lymphocy- 
tosis abso- 
lute. 



Lympho- 
mata. 



A remark- 
able case. 



Blood find- 
ings, the 
only means. 



of the disease is the tendency to hemorrhage from mucous membranes . 
These are often large, persistently recurrent, and demand that every 
patient should be duly warned and instructed concerning measures 
for their relief or control. They often prove a terminal event, or 
death may result from esthenia, or either gradual or sudden cardiac 
failure often associated with general dropsy. 

LYMPHATIC LEUKiEMIA.— The essential features of lym- 
phatic leukaemia are two in number, (a). Enlargement of the lym- 
phatic glands, (b). An absolute lymphocytosis in which either the 
large or small cell type may predominate. The chronic cases last for 
years, the acute cases may terminate in a month or six weeks. 

Symptoms. — Any or all groups of lymphatic glands maybe enlarged, 
the tumors are as a rule separate and movable, free from active 
inflammatory changes and there is little or no tendency to suppuration. 
The spleen may be moderately enlarged but the glandular symptoms 
predominate. Fever is present in variable degree in all acute cases 
and the later stages of the chronic form. Pressure symptoms may 
be marked and in three of the author's cases death occurred from 
suffocation due to the pressure of mediastinal growths. 

Blood Findings. — Nucleated red cells are rare as compared with the 
myelogenous leukaemias, though in the acute type of the disease they may 
be present in considerable numbers and the same is true of certain of 
the leukaemias of children; ordinarily, however, the normoblast pre- 
dominates. The leucocyte increase while striking is seldom as large 
as in leukcemia of the myelogenous type, the average lying between 200,- 
000 and 250,000 cells, the maximum being about 1,000,000, but in 
a case observed by the author the count reached 2,133,000 for the 
single examination possible and was probably a preagonal increase as 
it occurred but 24 hours before death. The remarkable predominance 
of the lymphocytic type (average 90%) is striking and the cells show 
many atypical forms. The myelocytes are relatively rare, eosinophiles 
are diminished and neither the mast cell nor the basophile are common. 

Differential Diagnosis of the Anaemias. — The enormous value of 
blood examinations is evident if one considers the difficulties surrounding 
the purely clinical differentiation of the conditions described as compared 
with the ease with which each disease may be identified by hematologic 
methods. As regards ancemia in any of its three chief forms and leukae- 
mia no confusion is possible and the two chief varieties of leukaemia 
are quite as sharply contrasted. The glandular enlargement of Hodg- 
kiris disease, tuberculosis and syphilis cannot give tlie slightest difficulty 



DISEASES OF THE BLOOD — POLYCYTHEMIA. 



407 



if the blood findings are invoked, nor can the various enlargements 
of the spleen be confused with myelogenous or lymphatic leukcemia. Cer- 
tain cases of profound secondary anaemia, particularly those associated 
with carcinoma of the stomach or atrophy of the gastric tubules (not 
merely the simple achylia gastrica) may at times present a picture almost 
indistinguishable from that of pernicious anaemia and to these may be 
added bothriocephalus anaemias which are probably symptomatically 
identical with pernicious anaemia proper. It is probable that in 
gastric atrophy the blood findings are always those of the profound 
secondary type. 

Subdivisions and Transition Forms. — It is quite possible that 
further subdivisions of leukaemia may be made in the future, and indeed 
many cases of variation in the relative predominance of cell types and 
apparent transition, are constantly being placed on record.* Von 
Jaksch has reported a multiple periostitis with splenomegaly and mye- 
locytic anaemia, multiple arthritis, profuse sweats and the same or 
an even greater tendency to the hemorrhages characterizing the later 
stages of myelogenous leukaemia. In chloroma the blood findings 
may be indistinguishable from those of lymphatic leukaemia but the 
clinical symptoms are strikingly different. Still has reported a syn- 
drome, the main feature of which is an infantile arthritis with enlarge- 
ment of the lymph glands and spleen, but lacking the blood findings of 
leukaemia and presenting usually the history of rachitis. 

Prognosis. — In anaemias of the chlorotic type the prognosis is always 
good unless it be a part of the clinical picture of gastric ulcer or incipient 
tuberculosis. Secondary ancemias are wholly dependent upon the 
possibility of removing the primary cause. Pernicious ancemia is 
probably invariably fatal, though long periods of apparent recovery 
may be noted. f 

As regards leukcemia, there is an invariably fatal termination though 
of late cures have been credited to the X-Ray treatment. It is probable 
that these cases will also prove fatal after a period of apparent arrest. 

POLYCYTHEMIA.— A more or less marked increase of eryth- 
rocytes above the normal count is observed in a great variety 
of conditions, some important, others trivial, and curiously enough 
the permanency of such a condition still remains unproven. It 

*The author has observed a case of apparently typical Hodgkin's disease 
become in all respects lymphatic Leukaemia. 

fThe longest duration of such a period of false cure personally observed 
was five years, a second period of about one year followed, succeeded by a 
rapidly fatal relapse. 



Still's syn- 
drome. 



Not un- 
common. 



408 



MEDICAL DIAGNOSIS. 



High alti- 
tudes. 



Multiple 
causes. 



A recent 
discovery. 



usually represents nothing more than blood concentration or stasis 
and in high altitudes is perfectly accounted for by the assumption that 
nature meets an actual need associated with the rare air and the dysp- 
noea first produced in a non habituated person. This assumption is 
borne out by the secondary partial reduction noticed in those who take 
up permanent residence. A similar increase may follow baths, hot or 
cold, massage, violent exercise and the administration of certain drugs 
or may be associated with the process of digestion, blood regeneration, 
vomiting, profuse sweating, the removal of exudates, profuse diarrhoeas, 
and, it is said, with myxcedema and acute yellow atrophy. Its presence 
in connection with organic heart disease, emphysema, stenotic dyspnoea 
and similar conditions affecting the circulation is readily understood. 

OSLER'S DISEASE.— (Cyanotic or "Cryptogenetic" Polycythe 
mia.) This peculiar disease or syndrome comprises:— (a). Marked 
increase of the red cells, (b). Cyanosis, (c). Enlargement of the spleen. 
(d). Frequently, hepatic enlargement, (e). Commonly, albuminuria, (f). 
Hyperviscosity of the blood, (g). Rapid coagulation. The disease 
was first noted by Saundby and Russell* and by McKeenf in 
1901, and in 1903 Osier's report of cases and masterly description 
brought the condition into prominence. In Cabot's^ series three of the 
four cases are peculiarly interesting because of the lack of constant rela- 
tion between the erythrocyte and leucocyte count and the entire failure 
of correspondence in either with the haemoglobin values. Haemoglobin 
values of 165 and even 200 have been reported but in one of Cabot's 
cases it was but 85 with a count of 8,484,000 reds and 15,000 whites, 
and in another of his cases it was 105 with a count of 11,352,000 reds. 
Moderate or absent leucocytosis is the rule. In reporting cases the 
chief clinical factors must be demanded as a polycythemia of marked 
degree may co-exist with cyanosis under other conditions. 

HODGKIN'S DISEASE.— (Pseudo-leukaemia, lympho -sarcoma - 
tosis, lymphadenosis, anaemia lymphatica, adenie, lymphadenie, etc.) 

Definition. — A disease characterized by hyperplasia of the lymph 
glands, with or without splenic enlargement (75%), and varying degrees 
of anaemia. 

Historic Note. — The disease was first reported by Malpighi in 1669, 
who did not recognize it as a distinct disease. Craigie, in 1828, differ- 
entiated the anatomical character of the glands from those of carcinoma 

* Lancet, 1901, Vol. 1. 

t Boston Medical and Surgical Journal, June 20, 1901. 

+ Clinical Examination of the Bloud, p. 71, 1904. 






hodgkin's disease. 



409 



and tuberculosis, but to Dr. Hodgkin (1832) we owe our first definite 
description of the disease as a clinical entity. It did not, however, 
attain general recognition until the sixth decade of the last century. 

Etiology. — The acute forms strongly suggest a definite infection, and 
by some this is believed to be tuberculous in its nature. The theory, 
however, has no substantial or well proven foundation, and the true 
cause remains unknown. 

Pathology and Morbid Anatomy. — The essential change is one of 
hyperplasia of the lymph glands involving primarily limited areas, 
but tending to extend widely. The cervical and inguinal glands are 
usually the first affected, the former giving to the disease its most 
marked characteristic. The tissues of the neck may entirely lose 
their normal outline, and the glands there and elsewhere tend to 
steadily enlarge without marked tenderness or symptoms of inflam- 
matory change. They tend to maintain their individual outline 
until late in the disease, and the skin usually remains unaffected 
and unattached to the subjacent tumors. When periadenitis occurs in 
the later stages lobulate tumors are formed which may lose the firmness 
characteristic of the earlier stages and become softened and rarely, 
may undergo ulceration. The deep glands above the trachea, those 
of the larger bronchi, of the mediastinum and retroperitoneal area 
become involved and in some instances form large tumors and greatly 
complicate the case. The spleen is enlarged in 75% of the cases and 
shows overgrowth of the lymphoid bodies. The marrow of the long 
bone may present much the same appearance as in spleno-medullary 
leukaemia, the liver and kidneys are likely to contain lymphoid tumors 
and both the lymph nodes and the bone marrow contain an excess of 
eosinophile cells. Microscopically the lesions show a proliferation of 
endothelial cells, the formation of giant-cells, increase in connective 
tissue, and overgrowth of the lymph nodes. 

The Blood. — There are no changes in the blood peculiar to this 
disease, the condition being one of secondary anaemia. 

Acute Hodgkin's Disease. — Certain cases develop so rapidly 
as to be properly called acute, and may run their course to a fatal 
termination in a few weeks. The symptoms are, however, not differ- 
ent from those of the chronic type, save that there is a certain concen- 
tration of all clinical phenomena. 

Symptoms. — The onset is insidious, save in acute cases, and the 
enlarged glands, usually in the cervical region, but sometimes in the 
groin and axilla, may first attract attention. The glandular enlarge- 



Lympho- 
mata with- 
out blood 
changes. 



Chronic 
form. 



A 



r 



410 



MEDICAL DIAGNOSIS. 



The Hodg- 
kin's collar. 






Bronzing 
possible. 



ment may primarily be either unilateral or bilateral, but extends and 
tends to become general. The changes in the neck and the peculiar out- 
line produced have given rise to the descriptive term "the Hodgkin's 
collar." As the disease progresses, though often only after several 
months, a considerable degree of secondary anaemia, and more or 
less progressive emaciation appear. If, as is not infrequent, the 
mediastinal glands take on a rapid growth, the pressure symptoms 
may be extreme and will precisely resemble those seen in any other 
mediastinal tumors (see p. 205), pain, cough and dyspnoea, paroxys- 
mal or continuous, being the chief symptoms. Fever is present in the 
advanced cases, and is usually of a mild hectic type. Splenic enlarge- 
ment is readily made out in three-fourths of all cases. 

Differential Diagnosis. — From tuberculous adenitis it is usually 
readily differentiated by the absence of marked inflammatory symptoms, 
a history of tuberculosis, past or present, by the excision, if necessary, of 
a small gland and its examination, and by the fact that tuberculosis is 
more generally unilateral, and that its tumors never attain a large size 
without marked evidence of inflammation and caseation. From leu- 
kaemia it is absolutely differentiated by the negative blood examination 
(see leukaemia, page 404). Syphilis must be differentiated by the 
history and presence of scars, and the difference in the character and 
extent of the glandular swelling, which in this disease, though more 
or less general does not often attain large size. True sarcoma tends 
to spread to other tissues. Simple lymphoma is localized and lacks 
the predominating symptoms of Hodgkin's disease. 

Unusual Symptoms. — An enormous number of symptoms might 
be named in connection with the development of glandular masses in the 
abdomen, amongst these being bronzing which results probably from 
pressure upon the solar plexus. One has only to bear in mind that 
large tumors may develop in remote regions producing exactly the same 
effects as would any other tumors in the same location. 

Prognosis. — The disease is almost invariably fatal, its course occupy- 
ing usually one or two years. Misleading periods of improvement 
followed by relapse are extremely common and this applies to both 
the general and local manifestations of the disease. 

PURPURA. — (Morbus maculosus.) Definition. — A morbid state 
characterized by subcutaneous hemorrhages with or without fever 
and other constitutional symptoms. 

Comment. — So ill-defined and little understood is this disease that 
an arbitrary classification serves the purpose of clinical convenience and 



PURPURA. 



411 



little more. It seems to bear a close resemblance to certain forms 
of urticaria, scurvy and haemophilia, and possesses but two constant 
and invariable symptoms, viz. :— Subcutaneous hemorrhages, and a 
prolonged blood coagulation period. Cases may be grouped under two 
general heads: — (i). Complicating purpuras, viz.:— those occurring 
in connection with (a) acute infections, (b) chronic diseases associated 
with cachexia. When purpura occurs in association with acute infec- signi 
tion it ordinarily indicates an exceptionally severe type of the disease, purpuric 
One may encounter it in typhoid fever, smallpox, malignant endo- f^acute" 1 
carditis, septicaemia, pyaemia, whooping cough and measles as well as in ' disease. 
the more virulent of the tropical diseases. In cerebro-spinal menin- 
gitis and typhus fever it represents the usual exanthem. Of the 
chronic diseases it is seen most frequently in connection with scurvy, 
pernicious anaemia and leukaemia, and not infrequently in tuberculosis, 
Bright's disease, Hodgkin's disease, syphilis, and in connection with 
various cardiac lesions, particularly those associated with marked 
degeneration of the myocardium. In epilepsy it is not uncommon and 
sometimes points the way to a correct diagnosis in cases of an obscure 
nocturnal type. In such instances it is usually slight and transient, 
often showing only on the face as an indistinct capillary streaking, 
which may last for a few hours or a few days. In hysteria, the same 
form may be present, or the rarer forms amongst which the most 
curious is the cruciform purpura in which the hemorrhages appear at 
points corresponding to the wounds of the Saviour on the Cross. It 
may be seen at once that in epilepsy, whooping cough and chronic 
heart disease mechanical strain plays a great part. (2). Arthritic 
Purpuras. — In the three forms of purpura coming under this 
class there is a joint involvement distinctly rheumatic in type. 
Under this we have: — (a). Simple purpura., (b). Peliosis rheumatica 
(Schonlein's disease), (c). Henoch's purpura. This classification 
need not be confusing if the following points are borne in mind: in all, 
the essential lesion is hemorrhage, all are accompanied by fever and by 
joint lesions, but: — Simple purpura is of a mild type and short dura- 
tion. It has no other distinguishing features. Peliosis rheumatica 
is much more severe with higher fever, more marked joint involvement 
sore throat usually at the onset and not only marked purpura, but 
frequently pemphigoid spots, purpuric edema and marked urticarial 
manifestations of the ordinary or giant variety. The distinct:: 
Pure, however, is the involvment oj joints to a marked degree. Henoch's 
Purpura.— Differs from the two already named, primarily, in the fact 



Cruciform 
purpura. 



Hemor- 
rhage t In- 
essential 
lesion. 



i 



412 



MEDICAL DIAGNOSIS. 



Differen- 
tiation 
possible. 



Vague 
theories. 



Atavism. 



Beware of 
"bleeders.' 



that gastro -intestinal symptoms such as nausea, vomiting, diarrhoea, and 
hemorrhage from mucous membranes are the predominating features, 
while arthritis is usually slight. In all other respects it may closely 
resemble the other forms. 

Purpura Hemorrhagica. — (Morbus Werlhofii). This terrible dis- 
ease may be rapidly fatal, and is characterized by severe and often 
intractable hemorrhage from any or all mucous membranes, associated 
with high fever. 

It will be seen from the foregoing description that though the basic 
symptom is the same in each and every variety the differences pre- 
sented are such as to permit of a clinical differentiation in most 
instances. 

HEMOPHILIA.— (Aima, blood, phinein, love). Definition.— A 
morbid state characterized by an extraordinary tendency to spontaneous 
or induced hemorrhage and an especial predilection for young males 
in succeeding generations. 

Etiology. — The actual cause is unknown; deficiency of fibrin is 
evident; and a peculiar thinness of the vessel walls, a neuropathic 
tendency and abnormal alkalinity of the blood have been advanced as 
unproven theories of causation. Age and Sex. It affects chiefly male 
children under ten years of age, cases being rare in the later years of 
life, and usually less severe in their nature. Heredity. — The disease 
furnishes one of the most interesting known examples of atavism; 
affecting male children through maternal heredity, the girls of a family 
seldom showing any hemophilic tendencies, yet passing it on to their 
male children. In one family in Switzerland, the disease can be traced 
back over 300 years. 

Symptoms. — Intractable nose bleed is most common, but hemor- 
rhage may occur from the lips, gums, throat, stomach, urethra, lungs, 
bowels or in the female from the uterine mucous membrane, though 
strangely enough labor is not ordinarily attended with extraordinary 
hemorrhage. No operation should be undertaken without some inquiry 
as to this condition, as information upon the subject is seldom volun- 
teered by members of these foredoomed families and slight wounds or 
bruises, even the puncture of the ear or finger for blood examination, 
the drawing of a tooth, the application of a leech or a vaccination, may 
bring about a fatal hemorrhage, and more extraordinary still is the fact 
that spontaneous hemorrhage from mucous membranes, the free shin 
{lobe of ear, tip of finger), may come on without any apparent excitign 
cause. The mortality is extremely heavy, and pseudo-rheumatic affec- 



HEMOPHILIA AND SCORBUTUS. 



4*3 



Once a 

scourge. 



tions are common, as are ecchymoses and hematomata, these showing 
its close resemblance to purpura and scorbutus. 

Prognosis. — A majority of male children of affected families die 
under ten years of age, though light cases occur in which after the age 
of puberty the tendency is lost. 

SCORBUTUS.— (Scurvy). A morbid state peculiarly dependent 
upon diet* characterized by profound weakness, anaemia, and a marked 
tendency to hemorrhage from the gums. 

Etiology.— The actual cause is unknown, but the conditions of its 
development are well understood. They are (i). A diet from which 
fresh vegetables, fruits and meats are excluded. (2). Bad air, over- 
crowding, over -work, deficient light. (3). Mental depression, is present 
in most cases. Up to within the last century scurvy was the scourge 
of seamen and of armies. During the Crimean war, there were 23,000 
cases in the French army alone. Military and naval expeditions had 
sometimes to be abandoned on account of outbreaks of the disease and 
East Indian ships frequently lost half of their crews in one voyage. 
In one of the early Arctic expeditions 50% of the members died of the 
disease. In a recent Antarctic expedition the effects of the factors 
mentioned above were clearly shown, though a better food supply 
prevented a general epidemic. Essentially, however, scurvy belongs 
to generations past. 

Symptoms. — The gums are spongy and bleeding, often ulcerating, 
purpuric symptoms are pronounced, areas of brawny induration appear, 
especially in the lower extremities, subperiosteal hemorrhages may occur, 
especially in children, and the swelling is commonly over the outer In children, 
aspect of the femur, but occasionally over the tibia and is in every case 
hard, tense and exquisitely tender. Epiphyseal suppuration may occur 
and in all cases hemorrhages into the joints and retina are not un- 
common. Physical weakness is extreme, there is pronounced and 
progressive mental depression and usually edema of the ankles. As 
occurring in children, scurvy is known as Barlow's disease, having boon 
described by Drs. Chcadle and Barlow, in 1878. As before stated, 
the most suggestive symptom in children is the subperiosteal extrav- 
asation. The child lies motionless, shrinks from the touch, and presents 
what is really a characteristic swelling, the author having scon, as a 
student, in Dr. Barlow's and Air. Edmund Owen's wards an immediate 
diagnosis on sight and touch in many instances. The disease is never 



*In a typical adult ease recently observed by the autln 
connection with diet could he traced. 



absolutely no 



1 



4 i4 



MEDICAL DIAGNOSIS. 



Peculiar 
syndrome. 



Etiologic 
paradox. 



Lost 

adrenal 

function. 



seen in breast fed children and occurs usually from the sixth to the 
sixteenth month. It derives its general interest from the fact that the 
other symptoms of scurvy as seen in the adult may be entirely lacking. 

ADDISON'S DISEASE.— (Morbus Addisonii). This was first 
reported by Dr. Addison of Guy's Hospital, in 1855, and in his mono- 
graph he attributed the ailment to a disease of the suprarenal capsules. 

Definition. — A disease characterized by progressive weakness, gastro- 
intestinal disorders and a peculiar pigmentation of the skin and mucous 
membrane. 

Etiology. — The exact nature of the causative factors remains as yet 
undetermined. An antecedent tuberculosis seems the most important. 
Various diseases may precede it but their direct connection in causation 
is unproven. Poor food, insanitation, excessive mental or physical 
labor are often associated factors, but may be only coincident. Males 
are affected much more frequently than females (60-70%). It is 
most common in middle age, yet cases have been reported in infants. 
Nearly 90% of these cases show demonstrable lesions of the suprarenal 
capsule, and in 80% of these instances the lesion is clearly tuberculous. 
In a relatively small percentage a lesion of the capsule is not evident, 
and furthermore, the suprarenals may be removed by operation or be con- 
genitally absent without of necessity producing the disease. Its relation 
to lesions of the abdominal sympathetic, demonstrable or otherwise, 
seems probable. 

Morbid Anatomy and Pathology. — Any one of several conditions 
may be found at autopsy, These are, atrophy, simple or due to chronic 
interstital inflammation, malignant disease of the capsule, extravasation 
of blood, inflammation or pressure affecting the semilunar ganglia 
and in a vast majority of cases tuberculous infection of the suprarenal 
itself. It seems probable that Addison's original theory, that the dis- 
ease was due to a loss of function on the part of the adrenals is correct, 
though this cannot at present be absolutely proven. The involvement 
of the semilunar ganglia may materially affect the secretions of these 
glands and contribute to the symptom complex. This view seems on 
the whole more rational than that advanced by some observers, which 
holds the nervous system entirely responsible for the disease. 

Symptoms — The disease is insidious in its approach; is rarely 
suspected until pigmentation becomes well marked ; the gastro -intestinal 
disturbance as well as the loss of strength tends to increase, yet there are 
cases showing long periods of latency and relative immunity from 
vomiting, nausea and diarrhoea. A slight secondary anaemia is usually 



ADDISON'S DISEASE. 



415 



Mucous 
mem- 
branes. 



present, but is not an important factor. As the disease progresses, 
attacks of syncope, vertigo and palpitation may be troublesome. Vomit- 
ing may become persistent, and indeed uncontrollable, sometimes ending 
fatally, and again subsiding after several days. A history of tuber- 
culosis, past or present, in some other part of the body is often obtainable. 
The pigmentation of the skin is very variable in its intensity, the typical Pigment 
case showing a deep bronze color that is quite unmistakable though tion. 
the early pigmentation may be little more than a brownish yellow or 
definite brown, and, rarely, the case may die before this deepens to the 
typical shade. It shows certain interesting and important character- 
istics as regards distribution, in that it is most marked in the portions 
of the body exposed to light, such as the face and hands, and to those 
exposed to pressure or friction from clothing, being emphasized in the 
axilla, groin, under the breasts, or at the waist line and knees. Areas 
of pigment atrophy often appear making a sharp contrast and the 
mucous membranes of the lip and buccal surfaces especially are likely 
to show patchy pigmentation. 

Diagnosis. — The diagnosis is ordinarily easy in view of the grouping 
of progressive loss of strength, marked gastro-intestinal disorders and 
the peculiar pigmentation as above described. 

Differential Diagnosis. — Verminous bronzing is rarely seen except 
in the clinics of the great medical centres, being due to the constant " Yaga- 
presence of vermin attended by scratching, which results in a more disease, 
or less profuse pigmentation; in most instances the attending signs 
would be lacking as would certainly be the mucous membrane pig- 
mentation.* Cirrhosis of the Liver. In a few instances hepatic cir- 
rhosis in its last stages may produce a marked pigmentation, but in 
such instances there is almost always abundant evidence that the color ^on 6 ™ 
is due to an actual jaundice. In no such case in the author's experience 
has any such doubt arisen. Argyria (chronic silver poisoning). 
Is excessively rare at the present day, and the color is quite different 
from the pigmentation of Addison's disease, being more distinctly 
gray, and when excessive, showing a distinct bluish black tint; moreover, 
it is ordinarily limited to the face and hands, and the associated symp- 
toms of the latter disease are absent. Many diseases are accompanied 
by pigmentation and peculiar patchy discoloration, i.e. malignant 
disease, involving the abdominal organs, certain cases of tuberculosis. 
of chronic nephritis, etc., but it does not seem that the difficulties in 

* In such cases as have been observed by the author, the likeness was 
only sufficient to drawing a passing reference. 



Jaundice. 



1 



416 



MEDICAL DIAGNOSIS. 



Tuberculin 
test. 



Variable. 



" Thymus 
death." 



diagnosis are so great as to permit us to accept the dictum of Leube, 
to the effect that one "should forego any diagnosis of affections of the 
adrenal bodies." The tuberculin reaction sometimes offers some 
confirmatory evidence. 

Prognosis. — The disease is almost invariably fatal, usually within 
one or two vears, the last case observed by the author died after an 
illness of only a few months' duration. In rare instances life is prolonged 
for more than a decade. 

LYMPHATISM.— (Status lymphaticus, constitutio lymphatica). 
Definition. — A morbid state characterized by coincident hyperplasia 
of the lymph nodes, spleen, thymus, lymphoid bone marrow and in 
hypoplasia of the heart and arteries and showing a decided tendency 
to sudden death. 

Historical Note. — The discussion of this curious condition is really 
a revival of ancient knowledge. Nearly three centuries ago the 
association of an enlarged thymus with sudden death is said to have 
been noticed by Plater, and the thymic asthma was described by Kopp 
in 1830. This he regarded as a pressure asthma, later discussions occur- 
red, when the subject was again dropped to be renewed during the 
past few years. 

Etiology. — Little is known of the etiological factors, but the disease 
is one of youth and early childhood. 

Symptoms. — The symptoms upon which a diagnosis must be based 
are essentially pale, pasty, rachitic or tuberculous aspect, enlargement 
of the spleen and of the superficial glands, usually associated with 
tonsillar hypertrophy, adenoids and dulness over the sternum. The 
thyroid may be slightly enlarged, and there may be evidence of the 
involvement of the mesenteric glands. The chief importance of the disease 
lies in its relationship to early and sudden deaths in the young, both as 
occurring without apparent cause and in connection with operative 
or therapeutic procedures, the so-called "thymus death." This as- 
sumes considerable importance to both the physician and surgeon, 
cases having been reported as following adenoid operations, ancesthesia, 
administration of antitoxin, convalescence from various infections, and 
croup. Paltauf ascribes to this condition many of the cases of sudden 
death in children. The condition merits further study and observa- 
tion, and its symptomatology should be kept clearly in mind. These 
cases will usually show a relative but not an absolute lymphocytosis. 

MYXCEDEMA. — (Cretinism, cretinoid change, etc.) Definition. 
— A chronic functional disorder of cellular metabolism associated 



Relative 
lymphocy- 
tosis. 



Athyrea. 



MYXCEDEMA. 



417 



with structural changes and impaired function on the part of the thy- 
roid gland. 

Classification. — Although lacking in essential differences, three 
groups may be distinguished. First, cretinism or myxcedematous 
changes in the infant or young child. Second, myxedema proper as it 
appears in the adult. Three, operative myxcedema, which covers the 
changes attending the complete removal of the thyroid gland. 

Symptoms of Myxcedema- 
tous Change. — The symptoms 
are essentially alike for all three 
groups showing myxcedematous 
changes. 

Etiology. — That loss of func- 
tion usually but not invariably 
associated with atrophy of the 
thyroid gland is directly re- 
sponsible for myxcedematous 
changes has been well estab- 
lished by both clinical and ex- 
perimental observations. The 
disease attacks women five times 
more often than men, is peculi- 
arly frequent in certain coun- 
tries and districts, and in the 
case of cretinism seems to be 
markedly hereditary; the off- 
spring of people who have re- 
moved from regions where 
cretinism is endemic showing a 
marked tendency to the disease 
whatever the nature of their 
new environment Congenital 
syphilis, a tubercular taint and 
rachitis seem to favor the de- 
velopment of the disease in 
children and infants. In these the disease is ordinarily directly due 
to congenital atrophy or deficient function, but does not make its 
appearance for several months after birth as a rule, and sometimes 
not for many years. 
Symptoms of Cretinism.— The appearance of the affected child 
27 




Fig. 160.— Cretinism. (Courtesy 
of Dr. Henry Jackson.) 



Cachexi; 

strumi- 

priva. 



4i8 



MEDICAL DIAGNOSIS. 



The cretii 



Arrested 
develop- 
ment. 



Acute my 
oedema. 



is characteristic and unmistakable. The face is senile, coarse and 
stupid, the lips and eyelids are thickened and overgrown, tongue often 
protrudes from the mouth, the root of the broad, -flattened nose is depressed, 
the head is large, clumsy and rests upon a thick, short neck, the stature 
is dwarfed, and a child of 14 or 15 appears often to be but 2 or 3 years 
old. The legs are bowed, the abdomen is prominent, the joints are 
thick and clumsy, the gait is awkward, dragging, laborious and marked 
lordosis is often present. The skin is sallow, the hair is often thin and 
brittle, the skin usually dry though it may be greasy, and signs of arrested 
mental development are as striking as the physical appearance, the con- 
dition being usually distinguishable from other forms of idiocy. The 
fontanels remain open and muscular weakness is usually marked. Cre- 
tinism may be endemic or sporadic, and a peculiar form described 
is the result of an atrophy of the thyroid with an acute febrile disease. 

Symptoms of Myxcedema in the Adult. — The skin is dry, harsh 
and pasty, the hair is lustreless and brittle, the face is peculiarly moon 
shaped and lacking in expression. The features are clumsy and coarse, 
the nostrils broad, lips thickened and mouth enlarged, both thought and 
motion is slow and clumsy, the whole body shows an increase in bulk, and 
the superficial tissues have an appearance like edema, yet show no pitting 
on pressure. Large pads of firm inelastic tissue usually appear above 
the clavicles, and the hands and feet are pudgy and clumsy. Head- 
ache may or may not be present, irritability is usually marked, and 
actual delirium, hallucination and even true insanity may develop. 
The function of the organs in general is normal and though albumin- 
uria and glycosuria have been reported they are probably merely an 
accidental association. The course of the disease may extend over a 
period of from 10 to 20 years, the patient dying of intercurrent disease. 
Osier reports what is apparently a case of acute myxcedema and in some 
cases it seems to have been associated with the development of exoph- 
thalmic goitre. The author has reported a case in which symptoms of 
myxcedema co-existed with those of acromegaly.* 

Operative Myxcedema. — Does not differ materially from that 
described above. This condition is rare because it necessitates for its 
development the complete or almost complete removal of the thyroid 
gland. 

Diagnosis of Myxcedema. — In the adult this must depend upon 
the peculiar color, marked edematous aspect of the body, and the failure 
of the bulky tissues to pit on pressure, combined with the physiognomy 

* See Transactions of the Association of American Physicians, 1905. 



EXOPHTHALMIC GOITRE. 



419 



Insufficient 
evidence. 



Parry's, 
Graves', 
Basedow's 

or Flajani's 
disease? 



Hyper- 
thyrea. 



and mental state of the patient. Osier properly warns the clinician 
against laying undue stress upon the supraclavicular pads. As a 
matter of fact, this condition is very commonly seen in any stout person 
otherwise in perfect health. The improvement of all symptoms under 
the administration of thyroid gland offers conclusive proof of the nature 
of the disease but loss of bulk alone is not sufficient evidence. 

EXOPHTHALMIC GOITRE.— Definition.— A disease character- 
ized by prominence of the eyeballs, rapid pulse, enlargement of the 
thyroid gland and fine tremor associated with marked nervous mani- 
festations. It may assume an acute, subacute, or chronic form, the last 
being the one nearly always encountered. The names of Basedow and 
Graves have apparently been improperly used in connection with this 
disease, and it should be called Parry's disease, as he described it 
quite fully in 1825, indeed having made notes of a case as early as 
1786, half a century before the description of Basedow and Graves 
appeared. (Osier.) 

Etiology. — The disease is due to disturbed thyroid function (probably 
hypersecretion), the exact nature of which is unknown. It is rare in 
men, quite common in women, and appears usually between the ages of 
20 and 40. It seems to be well established that violent or depressing 
emotion even though transient may produce it and in some instances 
it has seemed to the author that there was a marked sexual element. 
Despite its marked nervous symptoms it is probably not properly clas- 
sified as a disease of the nervous system but rather of the thyroid 
gland itself. 

Symptoms. — Various authors have reported acute cases presenting 
the cardinal symptoms with marked gastro-intestinal disturbances 
and profound and progressive cardiac weakness, i.e. precisely the 
same phenomena that may bring a chronic case to a fatal end. Ordi- 
narily, the onset of the disease is gradual and progressively slow, its 
tendency being towards increase in the severity of all symptoms but 
usually with marked recession periods if under treatment. 

Thyroid Enlargement.— It usually involves both lobes, but not 
equally and may be unilateral. Venous bruit and loud systolic or 
double murmurs are commonly heard, there is usually a palpable thrill 
and often a visible pulsation in which the whole gland may participate. 

Exophthalmos. — This protrusion of the eyeballs varies greatly in 
degree, and it is said may become so great as to actually dislocate the 
eye.* The change is almost invariably bilateral, the vision is seldom 

*No such extreme cases have ever boon observed by the author. 



Acute 
cases. 



Usual 
second 
sj mptom 
to appear. 



420 



MEDICAL DIAGNOSIS. 



Over-rated 
signs. 



May for a 
time exist 
alone. 



" Formes 
frustus" 
important. 



Nervous 

symptoms 
marked. 



Mental dis- 
turbances. 



affected, but much stress has been laid upon three so-called signs in 
connection with exophthalmos. These are: — (i). The failure of the lid 
to follow the downward movement of the eyeball (Graefe'ssign). (2). 
Spasm or retraction of the upper lid (Stelwag's sign), and deficient 
convergence of the eyes (Moebius' sign). The first two are practically 
useless on account of the rarity with which they are observed and all 
three are somewhat superfluous clinically. The characteristic asso- 
ciated appearance in any considerable grade of exophthalmos is the 
rim of white which appears between the corneal margin and both lower 
and upper lids but this is not necessarily due to either spasm or lid 
retraction. Rapid Pulse. — This is often the first symptom to attract 
the attention and the pulse rate may vary from 90 to an uncountable 
beat, as is frequently seen in fatal cases. The pulse may be regular 
or irregular; peripheral pulsation is marked and a capillary pulse is 
often present as is the venous pulse. All sorts of bruits may be heard 
at the base and over the gland or the vessels of the neck, and a systolic 
murmur is seldom lacking in the mitral area. Such murmurs are 
sometimes autoaudible, or to be heard at a distance, the subjective sen- 
sation of throbbing is often most harassing, the heart action increased, 
violent, often tumultous, and its area of visible pulsation greatly ex- 
tended. Tremor. — A fine involuntary tremor usually attacks the head 
i and extremities, and is of great importance, as constituting one of the 
earliest symptoms of the disease. Tremor and rapid heart action may 
be present without exophthalmos or goitre. 

Subsidiary and Complicating Symptoms. — A vast number of 
symptoms may be encountered in connection with the course of the 
disease. Ordinarily extreme nervousness, subjective sensations of 
throbbing, flashes of heat, excessive perspiration general or local, 
cardiac distress and mental irritability are those most marked. Less 
common are the marked gastro-intestinal disturbances, complicating 
myxcedemas, angio-neurotic edema, pigmentation or leukoderma of 
the skin, and serious mental depression.* Melancholia has been the 
common form observed, though acute mania sometimes occurs. Ema- 
ciation is often extreme in advanced cases; on the other hand one fre- 
quently meets with those of the well nourished type. The disease 
is ordinarily chronic, lasting for several or many years, it is moreover 

* In one case coming under the author's observation an insanity devel- 
oped with delusions of so unfortunate a nature as to involve wholly inno- 
cent parties in a serious scandal the later development of the case making 
all clear. 



ACROMEGALY. 



421 



frequently curable or may disappear under medical treatment. The 
author has thrice seen an acute firm enlargement of the thyroid gland 
associated with marked nervous symptoms, tremor and tachycardia, which 
lasted but three or four days.* Swelling of the thyroid gland, whether 
inflammatory or non-inflammatory, suppurative or non-suppurative, is 
not unusual and enlargement of the thyroid is so common in young 
girls at the age of puberty and in young women at the time of their 
first pregnancy as hardly to deserve notice. The surgical conditions of 
the thyroid cannot be considered here, but it should be said that the 
accessory lingual thyroid may attain a large size and that its removal 
is said to have been followed by myxcedema. 

ACROMEGALY.— (Acromegalia. Marie's disease). Definition. 
— A chronic nutritional disease, characterized by progressive enlarge- 
ment or over -growth of certain portions of the body, chiefly and 
primarily affecting the bones of the hands, feet and face, essentially 
chronic and progressive in its course and tending to a fatal issue. 

Historical Note. — It was first described by Marie in 1886, having 
existed for thousands of years without recognition as a clinical entity, 
though presenting one of the most striking pictures known to medicine. 

Etiology. — The cause of the disease is unknown, though the fact 
that in nearly every case that has come to autopsy, the pituitary- gland 
has shown definite changes points to that curious structure as the prob- 
able source of the disease. The pituitary gland is a secreting organ as 
regards its anterior portion, whereas its posterior lobe has evidently a 
nervous function as its duct has become atrophied in the process of 
structural development, the secretion has become an internal secretion 
taken up by lymphatic absorption. There is much to support the belief 
that it is the centre for body growth and that it bears some curious 
but little understood relation to the thyroid gland. A relation between 
gigantism and acromegaly has been suggested and is probable. The 
disease occurs more frequently in women than in men, usually begins 
in early adult life, almost never after the age of 40, and no recognized 
pre-existing disease has been definitely connected with it. 

Symptoms. — It is essentially a case for street ear diagnosis, being 
easily recognized by its outward signs. The face is elliptical in form. 
the superciliary ridges are pronounced, the head often large and massive. 
the lower jaw prognathic, the features enlarged, coarse by reason of the 
marked thickening of the greasy integument, in which appear deep 
creases, especially marked across the forehead. In many cases, even 

*The Last cast- two weeks. 



Pituitary 

gland 

affected. 



Usually un- 
mistakable. 



422 



MEDICAL DIAGNOSIS. 



the lids are thick and coarse, the hands and feet are enormously 
enlarged, the fingers are spatulate and clumsy, and upon examination 
the increase is found to depend upon the bony over-growth a finding 
easily verified by the X-Ray. This growth may extend for considerable 
distance upwards along the bones of the forearm and leg, and sooner or 
later tends to involve the clavicles, scapulas, ribs and spinal column at 
which time the patient is likely to assume a peculiar stoop, due to 
kyphosis of the spine. There are no constant symptoms so far as the 
internal organs are concerned, and decided subjective symptoms, such as 
headache, mental irritability, malaise, joint pains, disturbance of vision 




Fig. 161.— Acromegaly showing enlarged and clumsy bones (case of L. G.). 

or drowsiness, may be absent until the later periods of the disease. 
The tendency is towards a fatal termination after a long term of years, 
in some cases covering two decades, and the symptoms are subject to 
many variations and exceptions. In a case which has been under the 
author's observation for nearly a decade, most interesting variations 
have been observed.* In this case the predominant facial hypertrophy 
* Transactions of the Association of American Physicians, 1905. 



ACROMEGALY. 



423 



in the bones of the face appeared in the upper jaw; the bones of the feet 
were but slightly hypertrophied as compared with those of the hand, 
yet after a term of years marked localized over -growth appeared in both 




Fig, t6a.— Acromegaly, 



show Ing predominant hypertrophy of great toe 
(case of I.. G.). 



great toes. Another rare phenomenon was a co-existing mvxivdema. 

which promptly disappeared each time that a course of thyroid medica- 
tion was applied, finally disappearing altogether at a time when a 
previously existing marked enlargement of the thyroid gland slowly 



An unusual 
case. 



424 



MEDICAL DIAGNOSIS. 



subsided. In this case also there was from the beginning a chronic 
synovitis of the knee joints, persisting and so weakening the ligaments 
as to permit displacement of the patella and render the patient liable 
to dangerous falls. At the present writing this individual still lives, 
but grows gradually weaker and is subject to attacks of vertigo and 
occasional syncope. 

Differential Diagnosis. — Acromegaly may be associated with gigan- 
tism and it is said may be mistaken for myxcedema, leontiasis ossea, 
osteitis deformans, arthritis deformans, and pulmonary hypertrophic 
osteoarthropathy. There is hardly a shadow of an excuse for any 
error along these lines. Gigantism need not be considered as the over- 
growth is symmetrical. Osteitis deformans is rather a matter of deform- 
ity than over-growth, and in it the cranial bones are chiefly affected, 
rather than the facial bones as in acromegaly. Furthermore, the shape 
of the head in osteitis deformans is characteristic, its broadened cranial 
portions contrasted with the narrower maxillary region, a condition usu- 
ally reversed in acromegaly. Leontiasis ossea shows merely bony tumors 
on the skull and face, and lacks every characteristic of acromegaly. 
In pulmonary hypertrophic osteoarthropathy enlargement of the hands 
and feet exists, but is confined chiefly to the articulations. The face is 
not affected, and chronic pulmonary disease of some sort is an invari- 
able accompaniment. 

OSTEITIS DEFORMANS.— (Paget's disease). Definition.— A 
rare disease characterized by kyphosis of the upper spine. A broad 
based thorax, lozenge shaped abdomen. Marked enlargement of the 
cranial portion of the head and enlargement and deformity of the long 
bones, due to a rarefying osteitis. The disease is extremely rare and 
of unknown etiology and needs no further description. 

LEONTIASIS OSSEA.— A disease characterized by hyperosteitis 
of the bones of the cranium, rarely those of the face, in some instances 
combined with localized hypertrophy of the soft tissues. 

MICROMEGALY. — This disease is the opposite of acromegaly, is 
excessively rare, and of unknown causation. 

PULMONARY HYPERTROPHIC OSTEOARTHROPATHY.— 
(Bamberger's disease). This ailment, associated almost invariably with 
chronic pulmonary disease, is characterized by an enlargement of the 
hands and feet, the distal portions of the long bones, joints and term- 
inal phalanges chiefly being affected. The finger nails become brittle 
and show longitudinal striation. 

RICKETS. — An infantile disease characterized by general impair 



RACHITIS. 



425 



merit of nutrition and peculiar changes in the bones. Etiology.— Poor 
food and unsanitary environment quite frequently associated with a 
syphilitic or tuberculous hereditary taint and relatively rare in breast 
fed children. 

Symptoms. — The child appears delicate superficially and struc- 
turally with small bones, less rigid than normal and showing at the 
epiphyses, especially of the wrists and ankles, characteristic swellings 
found at autopsy to be associated with imperfect ossification. In the 
parieto -occipital region the bone yields to -finger pressure and in certain 

areas there may be a parch- 
ment like crackling. The 
broad forehead carries promi- 
nent frontal bosses due to hy- 
perostosis, the ribs show the 
peculiar and characteristic bead- 
ing at the chondro-costal junc- 
tion and there is frequently 
pigeon breast {pectus carinatus) . 
The abdomen is prominent, the 
liver and spleen are usually 
enlarged and autopsy may show 
changes in the mesenteric 
glands. Such a child shows 
either an inability to walk or 
creep about or if walking may 
suddenly develop apparent 
weakness or disinclination. 
There may be slight fever, the 
child is tender when touched or 
moved and extremely restless 
at night, the pillow being 
soaked with perspiration and the hair often rubbed away at the 
occiput. As might be expected gross rickety deformities are common. 
Spinal curvature, usually but not always, anteroposterior appears and 
bowlegs of the most extreme type may be encountered. Persistence 
0) the fontaneUes is a common symptom. The diagnosis is not likely 

to be missed in well marked eases but the slighter varieties occurring 
under unexpected conditions may cause trouble. 

Prognosis. The disease may indirectly eanse a large mortality bv 
weakening the child's resistance to other diseases but there is no direct 




Joints. 



Cranio- 
tabes and 
frontal 
bosses. 



Fig. 163.— Hand: — Case of pulmonary osteo- 
arthropathy. (Preceding page J 



" Ricketty 
rosary " 
and pigeon 
breast. 



Backward- 
ness and 
tenderness. 



Persistence 

oi fonts- 

nelles. 



J 



w 



426 



MEDICAL DIAGNOSIS. 



mortality. The development may be long delayed and permanent 
lack of resisting power and various deformities be left behind. 

INFANTILISM. — Closely related to myxcedema and cretinism is the 
curious condition termed infantilism of the Lorain type or those described 
by Gilford as ateliosis and progeria. The former type (Lorain) rep- 
resents merely man or woman in miniature. In the latter (Gilford) 
there is an asexual type representing delayed development and a sexual 
form represented by the ordinary traveling showman's dwarf, the 
delayed development in this case yielding along sexual lines at puberty. 
Progeria covers cases of infantilism associated with premature senility 
outward and structural. Pancreatic Infantilism.— This condition 
characterized by a marked amelioration under the administration of 
pancreatic extract is described by Byrom Bramwell.* In this case 
the developmental arrest was complete for 9 years but in the course 
of 9 months' treatment there was a gain of 8| lbs. in weight and 
nearly 2 inches in growth. The patient was 18 years of age, his 
developmental arrest occurring at 11 or 12. The various classifications 
of infantilism are unsatisfactory and probably do not rest upon a 
very substantial basis. 

OBESITY. — Obesity may be general or local, and its cause may be 
excessive food consumption, defective oxidation or elimination, lack 
of exercise or a distinctly hereditary tendency. In view of the discom- 
fort caused by the excessive accumulation of fat, its tendency to limit 
proper exercise and impairment of the functions of vital organs such 
as the heart, one may fairly consider the condition as a morbid state, 
tending directly to shorten life. The general conformation of the body 
should be given weight and the large bones and unusual muscular develop- 
ment and a relatively small waist measurement are factors that materially 
modify the estimation of individual longevity. This means that excessive 
fat is the condition most feared. 

There are two distinct types of the obese, namely, the anaemic and 
the plethoric, with little to choose between them, so far as life expectancy 
is concerned. The obese are peculiarly liable to disturbances of the 
secretory organs, heart disease, asthma, diabetes, gall stones, gout, 
apoplexy. Furthermore, they succumb readily to severe acute infec- 
tions, and are bad subjects for major operations. 

General Comment. — As is well known, certain races or tribes 
deliberately cultivate obesity in their women, making the pudgy outlines 
of the Hottentot Venus their ideal of feminine beauty. In all races, 

* Clinical Studies, Vol. I, part 2. Jan., 1903. 



Shortens 
life. 



Lines to be 
drawn. 



THE INFECTIOUS DISEASES — TYPHOID. 



427 



90% of the cases of excessive obesity occur in women, furthermore, 
the condition is often congenital. Cases are reported in which a baby 
13 months old weighed 75 lbs., a child 4 years old weighed 256 lbs. 
In some of these less excessive cases the excessive fat of childhood dis- 
appeared largely in adult years. Cases of excessive weight have been 
reported that tax one's credulity to the utmost. Daniel Lambert is said 
to have weighed 730 lbs. A case was reported in Baltimore in which the 
weight was 850 lbs. and one from North Carolina is said to have reached 
1000 lbs. These cases are ordinarily shortlived, and the fact that few | 
really fat people attain advanced age cannot fail to strike even the lay 
observer. In a curious disease known as "adiposis dolorosa" the exces- 1 A di pos ; s 
sive accumulation of fat is associated with headache, pain, tenderness of dol orosa. 
tissues and mental disturbances. It would seem that these cases were 
probably in many instances actually examples of myxcedema, though it 
cannot be denied that sufficient evidence is at hand from reliable observers 
to establish such a disease as a clinical entity. In the true disease, the 
accumulation of fat ordinarily occurs in the form of bunches or nodules, 
though later becoming generally distributed. Its cause is probably 
trophic disturbance, and degeneration of the ultimate nerve filaments 
has been reported. 

THE INFECTIOUS DISEASES. 

TYPHOID FEVER.— (Enteric fever, typhus abdominalis). Defi- 
nition. — This acute general infection is caused by the typhoid bacillus 
and characterized by continued fever, enlargement of the spleen, a 
peculiar exanthem, diarrhoea or constipation, tympanites, abdominal 
tenderness, the diazo-reaction in the urine, and the agglutination 
reaction of Widal. 

Etiology. — The bacillus typhosus of Eberth (1880) is a small motile 
rod, possessing numerous flagella, easily grown in pure culture and 
staining readily though not by Gram's method. Its development in the 
body results in the formation of agglutinins and precipitins responsible 
for the almost pathognomonic test of Widal* Outside the body it resists 
cold and moderate dry heat, yet fortunately direct sunlight destroys it in a 
few hours and it is readily killed by ordinary antiseptics. In -water 
it lives but a few days if saprophytic organisms are present and in ice 
rarely longer than ten days or two "weeks, though instances have been 

♦ The test also proved the germ which, though previously accepted by 
reason of its constant presence and the fact that it could be recovered and 
grown in pure culture, had not fulfilled Koch's laws. 



Eberth's 

bacillus. 



Vitality of 
germ. 






Modes of 
convey- 
ance. 



The urine 
a menace 
as well as 
faeces. 



428 



MEDICAL DIAGNOSIS. 



reported in which living germs were recovered from ice after a period 
of nearly five months. In superficial soil and in the faces they may live 
for months unless exposed to direct sunlight or other unfavorable condi- 
tions, and this applies to dust and filter sand as well as ordinary earth. 
In milk, sweet or sour, in butter or in cheese they may persist for months, 
indeed milk is a favorable culture medium. Infection arises ordinarily 
through germs cast off in the fasces or urine, and, indirectly conveyed 
to the water or food supply of the individual. Though possible, direct 
contagion under ordinary precautions is so rare as to be almost negli- 
gible* It is evident that the germs may be conveyed by food, clothing, 
soiled fingers, house flies and even by dust, but almost invariably water 
or milk is the vehicle. One polluted spring may poison a whole city, 
and many American municipalities are criminally lax in the supervision 
of their water supply. Milkmen using water from infected wells for 
cleansing utensils or less innocent purposes frequently convey contagion 
to their patrons. Salads may become sources of infection when their 
components are grown on soil fertilized by infected material, and even 
oysters bedded along lines of sewage flow may become active sources 
of infection. 

Distribution of the Germs in the Body. — The infection is a general 
one, and almost any body fluid, secretion or excretion, may contain 
them. The urine is a peculiarly dangerous source of infection, con- 
taining germs in at least one-third of all cases, and oftentimes for long 
periods after apparent recovery. The organisms are constantly present 
in the faeces during the active stages of the disease, though often they 
cannot be demonstrated by present cultural methods. Spleen cultures 
and those from the blood and rose spots, yield positive results in the 
majority of instances. They may be found in the bile and even in 
sweat, sputum, serous exudates or the foci of suppuration. 

Modes of Entrance. — It is probable that all infections occur through 
the intestinal tract and in the vast majority of cases it is the intestine and 
its associated structures that show the most marked lesions. 

Varieties. — Following Osier, we may group cases as follows: — (1). 
Typhoid fever with marked enteric lesions. (2). Those of slight enteric 
lesions. (3). Cases with no discoverable intestinal lesions. (4). Mixed 
infection. (5). Pseudotyphoid cases or those due to the so-called 
paratyphoid germs. The first group comprises the vast majority 
of all cases. Groups two and three represent extremely rare find- 



* Osier reports about 20 cases of apparently direct infection as occurring 
during 12 years' service in Johns Hopkins Hospital. 



THE INFECTIOUS DISEASES— TYPHOID. 



429 



ings. Group four should be confined to those cases in which the 
secondary infection is caused by germs which favor the growth, and 
intensify the action of the original germ. Such are the ordinary 
pyogenic cocci, the pneumococci and the colon bacilli. The fifth 
group comprises those cases denominated paratyphoid. In regard 
to these it may be said that they are due to the so-called para- 
typhoid bacillus of Achard and Bensaud (1896), and the disease cannot 
be differentiated by its clinical manifestations, which are identical with 
those of true typhoid fever. The absence of the Widal reaction with the 
Eberth bacillus in a case clearly typhoidal in type is the best diagnostic 
evidence if paratyphoid cultures are unobtainable.* 

Pathologic Anatomy. — The germ may be recovered from the 
blood, mesenteric glands, spleen, bone marrow and intestinal lymph 
structures and readily cultivated. The almost constant and essential 
lesions are those found in the agminate glands known as Peyer's patches, 
and the solitary follicles of Lieberkiihn in the ileum and jejunum, 
the process being one of medullary infiltration. The simple follicles 
of Lieberkiihn are found in both the large and small intestine, Peyer's 
patches are found throughout the ileum and the lower jejunum. The 
follicles are at first grayish white and prominent, the inflammation 
increases during a week or ten days, then terminating by fatty 
degeneration and absorption, or more often in necrosis and ulcer for- 
mation involving the follicles alone, or exposing the submucosa and 
muscularis at the base of oval round ulcers, which unlike those of 
tuberculosis, tend to parallel the long axis of the bowel and lie opposite 
the mesenteric attachment, resulting in deep and extensive sloughing, 
the neighborhood of the ileocecal valve being usually the point of 
maximum change. The ulcer border may be undermined, the edge 
regular or irregular and the stage of actual necrosis ordinarily represents 
the third and fourth weeks of the disease. Hemorrhages, trivial or 
serious, may occur at any time, from the beginning of the ulcerative 
process to the completion of that of healing but death after cicatrization 
is a rare event. Perforation with septic peritonitis occurs in about 
5% of all cases and the danger of excessive tympanites during the later 
weeks of typhoid is evident. The perforation is ordinarily found in 
the ileum, rarely in the caecum or adjacent portion of the colon, or 
vermiform appendix, The spleen is enlarged and extremely soft. 
rupture may rarely occur either with or without traumatism, abscess 

* Furthermore the paratyphoid culture of one epidemic may not show 
constant clumping in tne disease of other epidemics. 



Pseudo- 
typhoid. 



Typhoid 

vs. 
Tubercu- 
lous ulcers. 



43° 



MEDICAL DIAGNOSIS. 



Milk leg. 



Protean. 



is rare, infarction not unusual. The liver is hyperaemic and shows signs 
of parenchymatous degeneration, rarely abscess, and the gall bladder 
not infrequently contains the germs and may be the seat of a cholecyst- 
itis. Kidneys. An acute nephritis or suppuration is rare, cloudy swell- 
ing and granular degeneration more frequent. Heart Lesions. Endo- 
carditis and pericarditis are extremely rare. Granular and fatty 
degeneration of the myocardium is common but is seldom a cause of 
death. The Arteries and Veins. Emboli and thrombi are not uncom- 
mon, venous thrombosis being the rule and having its most frequent 
seat in the femoral veins. Such a thrombosis constitutes one of the 
complications of later typhoid. Respiratory Organs. Splenization and 
hypostatic congestion are extremely common, infarction occurs in about 
5% of all cases but abscess, gangrene and pleurisy are extremely rare.* 
Nervous System. A specific meningitis in typhoid is extremely rare, 
severe headaches and delirium common. Mesenteric Glands. Their 
marked involvement is constant. 

Symptoms and Diagnosis. — No disease is at times more difficult 
to diagnosticate in its earliest stages, none save influenza and syphilis 
more interesting and protean in its forms, none more difficult to fore- 
cast and few more exacting in their demands upon the therapeutic 
resources of the clinician. Many cases are remarkably clear in their 
development and run an uneventful course, but the practitioner must 
recognize the atypical and beware of hasty conclusions in those 
apparently straightforward. The work of the last decade has greatly 
simplified the diagnosis of typhoid for those who have at hand the aid 
of the clinical laboratory or the simple means to be described, and 
clinical and microscopic tests have added enormously to our positive 
knowledge of the character and frequency of variations in type. 

Major Symptoms.— -(a). An insidious onset, (b). A continuous 
and somewhat characteristic temperature, (c). Enlargement of the spleen. 
(d). Rose spots, (e). A lowered pulse temperature ratio, (f). A low 
leucocyte count, (g). Ehrlich's diazo -reaction, (h). Agglutination test of 
Widal. (i). The recovery of typhoid bacilli from the stools, blood or urine. 

Minor Symptoms. — Of the minor symptoms, one may mention 
nose bleed, gurgling and tenderness in the right iliac fossa, the so-called 
typhoid tongue with its V-shaped red tip and brilliant edges, the pea 
soup stools, becoming a brilliant ochre in the later stages, headache, 
delirium and profound prostration. 

* Ulceration of the larynx has been reported but has never been observed 
by the author. 



THE INFECTIOUS DISEASES — TYPHOID. 43 1 



fever. 



testinal 
signs. 



Complications. — The two most important symptom groups are, 
those of hemorrhage from the bowel, and of perforation of the intestines. 

The Typical Case. — (Rarely seen). There is first a period of gen- [nsidious 
eral malaise (lassitude, aching head and limbs, loss of appetite, etc.), 
during which (or later) nose bleed may occur with diarrhoea or constipa- 
tion, more generally the latter. This condition progressively increases, 
slight fever is apparent and the patient takes to his bed. The fever Rising 
rises each night higher than the night preceding, receding each morning 
about one degree below the temperature of the preceding evening. The 
face becomes flushed, the tongue is heavily coated, save the tips and margins, 
which remain a bright angry red. An antecedent diarrhoea may now Gastro-in 
increase or replace constipation, or the latter condition may persist. 
Mental hebetude is marked and the pulse, heretofore somewhat slow 
and soft, becomes weaker and tends towards dicrotism. At the end of a 
week or ten days pale red papules, easily blanched by pressure, appear 
over the abdomen and lower chest usually in small numbers, and the Examhem 
spleen may be readily palpable. Tympanites may be a prominent and 
distressing symptom. By the end of the second week the fastigium 
is reached and all symptoms are intensified. Headaches and hebetude Mental 
are replaced by a low muttering delirium, and the pulse grows more 
rapid and dicrotic. The heart sounds are weaker, there is a tendency 
to congestion of the lung bases, the tongue grows dry and hard and sordes 
tend to accumulate upon the patient's lips and gums, the attitude of 
the patient indicates profound weakness, he sinks down in bed, lies Decubitus 
constantly in one position, which must frequently be changed by the 
efforts of the nurses or ward attendants. If diarrhoea is present, the 
pea soup stool of the earlier period is replaced by the light ochre stool 
of the latter typhoid. Tympanites is likely to be excessive and increases 
the danger of perforation. During two weeks the temperature is 
practically continuous, all symptoms are intensified, hemorrhage or 
perforation may occur and tendency to hypostatic pneumonia increases. 
In the fourth week there is a recession of symptoms, fever gradually 
subsides, the mind clears, the spleen shrinks under the ribs, tympanites 
lessens and the heart sounds and pulse are of better quality. Such a 
case offers no difficulty in diagnosis, but one must consider the com- 
mon variations. 

Period of General Malaise. Our experience during the Spanish - 
American war has shown how frequently there may be a sudden onset 
with chill and high fever. 

Nose Bleed.— Frequent but neither constant nor limited to typhoid 



"Abor- 
tive " cases. 



43 2 



MEDICAL DIAGNOSIS. 



Often 
atypical. 



Afebrile 
typhoid. 



The excep- 
tion. 



Present in 
two-thirds. 



Often 
obscured. 



Diagnosis 
and prog- 
nosis. 



fever. Gurgling and Tenderness in the Right Iliac Fossa. This much 
overrated symptom may be found in any diarrhoea! condition, and 
1 any extreme early tenderness is more suggestive oj an appendicitis than 
oj typhoid fever, moreover, in many cases of typhoid these symptoms 
are altogether lacking. The Typhoid Tongue. —Such a tongue is 
strongly suggestive of typhoid but is not always present, many may 
occur in other conditions associated with high temperature and gastro- 
intestinal disturbances. 

Fever. — "Step-ladder" temperature is somewhat rare in its typical 
form, and the use of cold baths has robbed it of much of its symmetry; 
moreover, as before stated, fever may occasionally rise rapidly with 
or without an initial chill, instead of gradually as in a typical case 
and terminate either by crisis or by lysis in a few days or after several 
weeks.* 

The So-called Abortive Typhoid. — The abortive typhoids are 
much more common than was formerly supposed, and still more 
extraordinary are those extremely rare cases lacking temperature, 
which have been verified by the most modern and exacting clinical 
tests. 

Diarrhoea. — This symptom is present only in a minority of the cases 
on milk diet, regular movements or constipation being the rule.f 

Rose Spots. — These, when present, are valuable diagnostic aids and 
a great source of comfort to the practitioner groping for a clew. They 
are present in about two-thirds of all cases, ordinarily few, scattered 
and limited to the chest and abdomen, they may be profuse and widely 
distributed, but unfortunately, are not limited to typhoid. J 

Enlargement of the Spleen. — In association with the general 
symptoms of typhoid this sign is of great value, but often an existing 
tympanites makes its determination impossible, and, moreover, it may 
be found in paratyphoid, acute miliar}' tuberculosis, malaria, septic- 
aemia and some of the tropical fevers. 

Disturbed Pulse Temperature Ratio.— A low pulse rate associated 
with high fever is a valuable confirmatory sign of typhoid infection, 
though by no means limited to this disease. It is, furthermore, a valuable 
prognostic sign indicating light infection or good resisting power. It 
should be remembered that pneumonia offers the same symptom, 

* Such cases were frequent amongst the young soldiers in the last war. 

f Speaking from personal observation. 

% A case coming under the author's observation a short time ago pre- 
sented the typical rose spots, but failed to react to the Widal test, and 
proved to be a case of miliary tuberculosis. 



THE INFECTIOUS DISEASES — TYPHOID. 



433 



and in either disease one may be misled in elderly persons, in whom 
a slow pulse may be the result of an obstructive aortic lesion or arterio- 
sclerosis. 

Recovery of the Bacillus from the Stools, Blood or Urine. — 
The introduction of the Widal test has made this difficult and unsatis- 
factory cultural method of investigation of little use to the practitioner. 
Spleen puncture will often yield a pure culture, but is neither necessary 
nor justifiable save in the rarest instances. 

Nervous Symptoms. — These are essentially those of the " typhoid 
state," and may be seen in any disease associated with overwhelming 
toxaemia. The low muttering delirium of the typical typhoid, and less 
often the mental hebetude (torpor) may be entirely absent, or, in rare 
instances, replaced by an acute maniacal delirium, which constitutes a 
most serious complication.* 

Misleading Variants. — Of the many curious variations in the gen- 
eral form of this disease may be mentioned (a) that associated with 
profuse and exhausting sweats which strongly suggest septicaemia, 
pyaemia, certain forms of malaria or ulcerative endocarditis; (b) those 
in which the onset is so distinctly pulmonary in its type as to lead to a 
diagnosis of pneumonia without regard to the underlying infection; (c) 
the tonsillo -typhoid form, often accompanied by erythema and simulating 
scarlatina; (d) the renal form in which symptoms of nephritis are 
prominent and misleading, and (e) the many variations due to compli- 
cating abscess and necrosis. 

The Important Factors in Accurate Diagnosis. — The essential 
thing is a proper appreciation of the lesser value of individual symptoms, 
and the greater one of the grouped signs. Aside from the Widal test, no 
one clinical symptom suffices for a diagnosis of typhoid, but many 
combined reduce error to a minimum and of those mentioned, nearly 
all are important in combination but of slight significance if isolated. 
Three symptoms have been reserved for separate discussion because 
of their great individual value. These are, first, a low leucocyte count. 
second, Ehrlich's diazo -reaction, third, the agglutination test of Widal. 
It has been amply proven that A of all cases of typhoid, unless compli- 
cated by a secondary infection, yield a subnormal or low normal leuco- 
cyte count, which tends to progressively decrease as the disease increases 
in severity. The exceptions represent, chiefly, blood concentration from 
vomiting or diarrhoea, or cold baths, A count of 15.000 may be regarded 

*A considerable number of true typhoids pass through the whole course 
of their illness without any marked mental disturbance, 

3$ 



Seldom 
necessary. 



Mental 
state. 



Sudorous. 

Septic. 

Pulmonary. 
Scarlatinal. 

Renal. 



Value of 

clinical 

picture. 



Valuable 
single 

symptoms. 



434 



MEDICAL DIAGNOSIS. 



Value in 
negation. 



Period of 
persis- 
tence. 



Diseases 
excluded. 



as the maximum thus produced, and, on the other hand, even in» com- 
plications counts as low as 1000 have been reported. Absence of a high 
count in the relation to a suspected complication does not furnish ab- 
solute proof of its non-existence but the presence of a high count with 
no profuse diarrhoea or vomiting is good proof of one. A moderate 
secondary anaemia is practically invariable in all cases. The "coagu- 
lation time" of the blood is increased during the height of the fever 
(favors hemorrhage), and shortened during convalescence (invites 
thrombosis). 

Ehrlich's Diazo-reaction. — This much maligned, misunderstood 
and faultily applied test is one of great value in the exclusion of typhoid, 
but cannot be used save with a thorough understanding of the con- 
ditions under which it appears, its limitations and the true typhoid 
reaction color.* The test recommended is that of Ehrlich as modified 
by C. E. Simon and the author. (See p. 349.) 

Limitations of the Diazo-reaction. — It cannot be too emphatically 
stated that the presence of a true typhoid diazo-reaction^ does not prove 
the disease to be typhoid; with equal emphasis it may be said that absence 
of reaction in a supposed case, provided the test be made at a proper stage 
of the disease, amounts to almost positive proof that typhoid is not present. 
This statement iterated and reiterated by the author ten years ago, 
has, in the last year or two, been abundantly confirmed by other observers 
using it in connection with the agglutination test. It may appear 
as early as the fourth day of a typhoid and is almost invariably present 
by the end of the first week or ten days. It becomes intensified as the 
disease progresses but rapidly fades as soon as the acme of infection is 
passed. This latter fact is an extremely important one, and a failure 
to recognize it has led to many errors. The reaction is present in 
many of the acute exanthematous diseases, but if made with the higher 
dilution as described on p. 349, will be found absent in malaria, most 
cases of appendicitis, pneumonia, and the earlier stages of acute miliary 
tuberculosis. Indeed its late appearance in the last disease is of con- 
siderable diagnostic value in that connection. 

The Agglutination Test of Widal. — This is by far the most im- 
portant and positive test of typhoid fever. It was first announced to 



*"The Diagnostic Value of Ehrlich's Diazo-reaction," Greene, Journal of 
the American Medical Association, Feb. 24, 1894. " Recent Aids in the 
Differential Diagnosis of Typhoid Fever," Greene, Medical Record, Nov. 
14, 1896. 

t Viz. : — that diazo-reaction which is so intense as to yield a brilliant 
crimson band and upon shaking a pink foam. 



THE INFECTIOUS DISEASES— TYPHOID. 



435 



the medical profession by Widal in 1896 * This test really depended 
upon the earlier discovery by Pfeiffer (May, 1894), who found that 
cholera vibrios mixed with the serum of an immune animal and injected 
into the peritoneal cavity of a guinea pig lost their motility and changed 
their form, and later on found that the typhoid germ reacted in a 
like manner with the blood serum of typhoid patients and applied the 
test to the identification of the germ. Widal reversed the process and 
applied it to the diagnosis of the disease. The test is as nearly path- 
ognomonic as any in the range of medicine, and in its simplest form may 
be applied by any practising physician.^ The method originally 
employed by the author, though rough and simple, was definite in its 
results and required merely an agar-agar (i.e. solid) culture of typhoid 
bacilli, a medicine dropper, a platinum loop, and distilled water. The 
loop being made of fine wire was so constructed as to leave a central 
opening of not more than one-sixteenth of an inch. The tests were 
made either with the fresh blood or the dry film, the latter being treated 
with a drop of distilled water before testing. Instead of the "hanging- 
drop" method, the ordinary flat preparation was used with equally good 
results. It was only necessary to place a drop of distilled water on two 
clean microscopic slides, take a small particle of the culture with a 
sterilized platinum loop and stir it into the drop of water. Sterilize 
the loop, and from a drop of blood obtained from the suspect allow the 
tiny loop to fill and stir this film into one of the drops containing the 
bacilli. A cover-glass was then dropped upon it, it was placed under 
the microscope and a reaction was indicated by loss of motility, and 
grouping of the germ, half an hour being the time set for a positive 
reaction, and reference being made to the control slide for error due 

* Bulletin Mcdicale, 1896, page 618. The papers of Wyatt Johnston 
(New York Medical Journal, Oct. 31, 1896) and of the author (Medical 
Record, Nov. 14, 1896, and Dec. 6, 1896), being the first reports published 
in this country. 

i"At the present time one may obtain the so-called typhoid aggluto- 
meter (Parke, Davis & Co.) by means of which the test may be applied 
without the use of the microscope. The agglutometer comprises three 
tubes containing (a). A sterile permanent suspension of typhoid bacilli. 
(b). A control tube of the same nature for the comparison of reactions. 
(c). Adilution tube containing fluid for properly diluting the serum previous 
to testing, (d). Tube for the collection of the blood to be investigated. 
(e). A pipette for the withdrawal of the serum, (f). A puncture needle. The 
test is made by adding two drops of the serum to the fluid in the diluting 
tube and this diluted serum is distributed in specific quantities in three 
tubrs of suspended material. If the reaction is positive floccules appear in 

one or more of the tubes in one or two hours, the reaction being readily 

determined by a comparison of the treated tubes with the control. 



Practically 
pathogno- 
monic. 



Rapid 
rough 
method. 



r 



43° 



MEDICAL DIAGNOSIS. 



Many 

methods. 



Author's 
macro- 
scopic test. 



As early as 
fourth day. 



Persistence 
period un- 
known. 



Its use 
imperative. 



The W'idal 
conclusive. 




to pseudo-reactions. Many methods are now in use providing for 
exact dilutions and the use of bouillon cultures, some far too complicated 
for the practitioner and requiring laboratory facilities, but from actual 
experience the author can recommend the extremely simple one above 
mentioned.* During this early period in tests thus made it was found 
that if a relatively large amount of the culture 
material was used a positive reaction could be 
determined in the same time and by the same 
method, without a microscope, through the ap- 
pearance of a dust-like film, which became visible 
when the surface of the cover-slip was viewed 
tangentially against the light. It may be added 
that in any event, oil immersion lenses are not Fig. t6 4 . -Typhoid ag- 

, i , i .i c e ±i glutination test. (Widal.) 

absolutely necessary to the performance of the Upper segment shows 
test, lenses of moderately high power being quite fhV "ImtS^th? fypkli 
sufficient. The author firmly believes that the " clum P in e-" 
simpler methods add rather than detract from the accuracy of this valu- 
able test and that a solid culture and relatively low dilution 1-20 give 
the best results. Slides and cover-glasses should be washed in pure water 
before using to remove any powerful antiseptics. Blood should never be 
taken upon paper or cardboard, but rather upon glass, porcelain or tinfoil. 

Time of Appearance. — If the fresh blood be used the reaction may 
be found as early as the fourth day of the disease. It is persistent 
throughout the illness and in some cases for years afterwards, but 
its exact duration has not been determined. Cases of delayed or 
even absent reaction have been reported, but the author has found 
none which have been delayed beyond the first ten days of the illness. 
A single negative test should never be considered sufficient. 

Value of the Test. — Even working with dried blood, competent 
observers report positive results in at least 95% of the cases tested. 
It corrects innumerable errors of observation and must be given not 
only first place in the diagnosis of typhoid, but a value at least equal 
to that of all other symptoms combined. It should be universally 
applied in city and country practice alike, and its teachings accepted 
in a proper spirit of humility. 

DIFFERENTIAL DIAGNOSIS.— Widal's reaction when practi- 
cable will almost invariably eliminate any doubt that arises, but in 
its absence one must depend upon the grouping of symptoms. 

*" Recent Aids in the Differential Diagnosis of Typhoid Fever" (Medi- 
cal Record, Nov. 14, 1896). 



THE INFECTIOUS DISEASES— TYPHOID. 



437 



Error 

seldom 
excusable. 



May re- 
quire \Y 
dal. 



Symptoms 
usually dis- 
tinctive. 



Acute Miliary Tuberculosis. — This differs from typhoid in its 
irregular temperature, the fever being often of the inverse type; chills 
and sweats, more rapid emaciation, the fact that rose spots are usu- 
ally absent, the late appearance of the diazo-reaction and splenic tumor 
and sometimes in the discovery of definite pulmonary symptoms.* 
The family history or known exposure to infection is often suggestive, 
but it must be remembered that typhoid and acute miliary tuberculosis 
may co-exist and that in both diseases there is a tendency to abnormally 
low leucocyte counts. 

Septicaemia. — As this disease is usually characterized by a distinctly 
' typhoid state" the focus of suppuration must be sought, and the irreg- 
ular temperature, with possibly chills and sweats, and a marked 
leucocytosis may point to a true diagnosis. It gives the diazo-reaction 
exactly as does typhoid. Ulcerative Endocarditis, Salpingitis. — Present 
much the same features with the added help of localized symptoms. 

Appendicitis. — This constitutes a not infrequent source of error, 
operations for appendicitis being made without justification and cases 
of appendicitis being treated as typhoid. Ordinarily, the localized 
symptoms and sudden onset with perhaps a previous history of similiar 
attacks serve to make the diagnosis clear. Early localized tenderness 
in the appendiceal region is rare in typhoid and in appendicitis the early 
colicky pain is almost invariable and the Widal test is negative. 

Meningitis. — This is sometimes to be distinguished from the cerebral 
form of typhoid only by the absence of the diazo-reaction, the failure 
of the Widal test, and diminished urinary chlorides, but ordinarily, 
no confusion of the two diseases is possible. 

Simple Continued Fever.— Can never be positively differentiated 
unless the two crucial tests are applied. 

Pneumonia. — Is a frequent complication of typhoid, but as an inde- 
pendent disease may be recognized by its sudden onset, marked 
localizing symptoms, high leucocyte count, absence of true diazo-reac- 
tion in high dilution (i-ioo) and of the Widal test. 

Malaria. — The remittent form can at times be differentiated only 
by finding the plasmodium in the blood, the absence of a diazo-reaction 
and a negative Widal test. In any malarial country a mistake in diag- 
nosis is extremely frequent. 

Paratyphoid. — As before stated this disease exactly simulates 
typhoid and can only be differentiated by the agglutination test. It 



Clinical 
"beU not 



*The author places much reliance upon 
(Vice in the earlier stages. 



mumuI pulmonary Jiy pcr-rcso>i- 



43» 



MEDICAL DIAGNOSIS. 



Widal'stest 
the only 
means. 



Private 

vs. 

Public. 



Epidemic 
variants. 



Physical 
condition. 



Sex. 



Symptom 
values. 



unquestionably furnishes an explanation of the few cases in which a 
failure of the Widal test has been reported in the face of a group of 
symptoms convincingly typhoidal in type and such failures can 
scarcely be proven without cultural or paratyphoid agglutination tests. 

Conclusion. — It is evident that both in direct and differential diagnosis 
the agglutination test may be the only determining factor, and that no 
practitioner of the present day can justify himself for its neglect. 

Prognosis. — The mortality of typhoid varies greatly according to 
the age of the patient, his condition at the time of its onset and the 
character of the epidemic, if such exist. It varies in private practice 
from 5-15%, in hospital practice it may reach 20%. Much depends 
upon the character of the hospital population and methods of treatment 
employed. The mortality of different epidemics varies widely in the 
presence of virulent infection, a picked body of men such as would be 
represented by a newly mustered volunteer regiment furnishing a low 
mortality. On the other hand, the same regiment after a long campaign 
is likely to furnish an extreme mortality.* The female furnishes a 
higher mortality than the male, and the so-called walking typhoid, 
i.e., the ambulatory form, presents, as might be expected, an excessive 
death rate. The temperature curve seems not to figure greatly, but pro- 
\ nounced nervous symptoms and high pulse rate, excessive meteorism 
and such complications as hemorrhage and perforation are of bad portent, 
the latter being almost invariably fatal even if prompt surgical measures 
are instituted. Hemorrhage occurs in about 5%, and perforation in 
about 3% of the cases. There is a marked tendency to relapse, especially 
if improper feeding be permitted during the period of convalescence and 
it is seldom wise to depart from the routine fever diet until the temperature 
has been normal for a week, though it sometimes requires the finest 
judgment to decide whether it is due to an obscure complication or the 
persistence of the infection and intestinal changes. The best guide 
is the condition of the abdomen; freedom from tenderness and rigidity 
(general or localized) being the safest indication for an increased 
dietary. 

INFLUENZA.— (La grippe, la cocotte, la follette, the "pleasant 
acquaintance," the " jolly rant," the "knock me down fever, " catarrhal 
fever, epidemic catarrhal fever.) 



Relapse. 



Increased 
dietary. 



Its misno- 
mers. 



*This is well illustrated by a comparison between the death rates of such 
of our own volunteer regiments as remained in camp, but out of service 
during the Spanish-American war, and the British regiments in South 
Africa, amongst whom the death rate was nearly trebled. 



THE INFECTIOUS DISEASES — INFLUENZA. 



439 



Early 
theories. 



Ancient 
epidemics. 



Historic Note. — Influenza has been known and recognized as 
a clinical entity for over 2000 years, though its true cause remained 
obscure until 1892, when Pfeiffer discovered its specific micro- 
organism. Its peculiarities led to many curious theories of causa- 
tion, and to such extraordinary names as appear above. Hippoc- 
rates ascribed it to the interposition of Providence, Syden- 
ham to some "occult and inexplicable changes wrought in the 
bowels of the earth." Weber would hold to a "negative state of 
electricity," and recommended the wearing of socks lined with non- 
conductors. Fogs, comets, earthquakes and various other disturbances 
were supposed to be concerned in its causation and over two and a 
half centuries ago there were advocates of a "contagium vivum." 
Influenza appeared in the Greek army at the siege of Syracuse and 
destroyed thousands of soldiers. In 1782, the fleet of Admiral Kemp- 
enfeldt was obliged to put back to port on account of the destruction 
of his crews and in 1728 it drove the imperial court of Russia from the 
city of Moscow. 

General Comment. — The enormous importance of influenza is 
hardly recognized even by the scientific world. Like cholera it follows 
lines of commerce and one can hardly escape the belief that it is always 
present in a large portion of the inhabited world. It would seem that 
more should be done in the way of quarantine and prophylaxis, for in 
spite of the many difficulties it offers, the author's experience would 
indicate that prompt isolation of an infected individual may prevent 
the infection of the remaining members of the household. 

Etiology. — The influenza bacillus of Pfeiffer is readily obtained 
from the secretions or from the blood of those suffering from the disease. 
It is small, non-motile and readily stained with concentrated stains such 
as alkaline methylene blue and carbol-fuchsin, but so deeply at the 
ends as to resemble diplococci. The bacilli are Gram negative, are 
cultivated with difficulty on blood agar and are solitary or less often in 
chains. They seem to thrive in the mucous discharges and may not 
only infect others, but, after a considerable period may also reinfect 
the individual. The disease does not confer immunity, but seems rather 
to render Us victim more susceptible to other attacks. 

Incubation. — The exact period is unknown, but varies from 24 
hours to one week. Two or three days is probably the average duration. 

Symptoms. — There are two classes of influenza, first, true epidemic 
influenza, second, endemic-epidemic influenza. The former is usually 
the more serious and fatal type, but aside from the severity o\ its 



The germ. 



One attack 
unite S 
others. 



Chief 
types. 



440 



MEDICAL DIAGNOSIS. 



Protean. 



Coryza-like 
attacks. 



symptoms and complications, is precisely like the second form. More- 
over, while possessing certain fairly well defined peculiarities, it is 
the most protean of acute diseases. Profound exhaustion, mental and 
physical, is its most constant feature, the mucous membrane and 
particularly that of the air passages its favorite seat, and, it attacks 
the nervous system with especial violence. Moreover, the epidemics of 
different years assume certain predominating features, some are espe- 
cially catarrhal, taking the form of coryza, bronchitis and pneumonia, 
in others, the nervous and cerebral types predominate, and in yet 
others the gastro -intestinal tract. Usually distinctly febrile, it may 
present an afebrile form or one in which the fever is so slight as to resemble 
an ordinary cold. These latter types are especially common in the 
endemic-epidemic forms. Its diagnosis, in the absence of a definite 
epidemic and even in its presence, is oftentimes rendered obscure by 
its simulation of a multitude of diseases, resulting either from its selective 
points of attack or from complications. Amongst these confusing con- 
ditions may be mentioned cerebral and cerebro-spinal meningitis, 
cerebritis with hemiplegia or paraplegia, intractable neuralgia, pleurisy, 
pneumonia, jaundice, vomiting, diarrhoea, dysentery, nephritis, suppura- 
tive or non-suppurative otitis media, endo- or pericarditis, thrombosis, 
embolism, melancholia, mania, neurasthenia, iritis, conjunctivitis 
and optic neuritis. In view of these complicating conditions as relating 
to diagnosis there is but one safe ground for the clinician to occupy, 
and that is to recognize and act upon the fact that in the absence of an 
epidemic, influenza may sometimes be recognizable only through the 



Diseases 

simulated. 



Cardinal 
points. 



Common 
type. 



Influenzal 
pneumo- 



recovery of the bacillus and the appearance of a degree of exhaustion 
entirely out of accord with the other symptoms presented. Mistakes in 
diagnosis must inevitably be common, excusable, and fortunately in 
most instances without serious results, inasmuch as the treatment of 
most complications is essentially that of the disease which they simulate. 
In by far the greater number of cases the symptoms are primarily those of 
an acute coryza and bronchitis. The pneumonias of influenza are com- 
monly broncho-pneumonic, though lobar pneumonia is very common, 
and either form may be due to an infection in which the bacillus of 
Pfeiffer directly participates. The author has observed two examples 
of pneumonia occurring in connection with influenza, both apical, with 
a marked and typical pneumonic onset, and characteristic physical 
signs associated with nausea, vomiting and diarrhoea, and rapidly 
assuming a dysenteric form. The cough, though urgent, was unpro- 
ductive, there was no localized chest pain and in 24 hours all physical 



THE INFECTIOUS DISEASES — CHOLERA. 



441 



Illustrative 
cases. 



Relative 

mortality. 




signs had disappeared, the fever subsided by lysis, the dysentery dis- 
appeared with the subsidence of the physical signs in the chest, but 
in each case the exhaustion was extreme and the recovery oj strength 
unusually slow. These cases are quoted merely to illustrate the extra- 
ordinary departures from the type to be seen in every influenza epidemic. 
A complete consideration of the vagaries of the disease would demand 
a large volume. 

Prognosis. — As has been said, influenza is a disease oj enormous 
actual but low relative mortality, that is to say that considering the ' Actual 
universality of an epidemic and the enormous numbers of individuals 
attacked, the death ratio is small, yet the total number of deaths is 
enormous and the indirect mortality adds greatly to the figure. Every 
practising physician knows how frequently one attack of influenza has 
proven to be the starting point of others and how often it has been 
the last straw in the case of those of failing health, whether from pre- 
existing chronic disease or old age. In the year 1900, over 16,000 
deaths were reported as due to influenza and it is probable that if one 
could get at the facts as to the indirect effects of the disease, such mor- 
tality figures would be multiplied fivefold. This 
enormous mortality, the fact that it kills the adult 
by preference, and especially those engaged in 
active productive work, should open the eyes of 
anitary authorities to the necessity for quaran- 
s ine regulations, both as applied to the State and 
tto the household. 

ASIATIC CHOLERA.— ("The death blow"). 
Definition. — An acute injection caused by the 
comma bacillus oj Koch and characterized by 
projuse rice-water diarrhoea, violent muscle cramps 
and collapse. 

Historic Note. — It is one of the most ancient 
of diseases in the East, but of comparatively 
recent development in the United States, the first epidemic having 
occurred in 1832. 

Etiology. — Koch reported his discovery of the comma bacillus 
in 1884. The germ retains its vitality for a week or more on food 
stuffs such as butter, milk and meat, lives but a day or two in oysters, 
but finds sewage a good culture medium. Water is a great conveyer 
and flies also carry it, but it travels no faster than man. following the 
trade channels, whether these be railways, canals, rivers or steamship 



Fig. 165.— Choler 
cillus (comma bacillus 
or spirillum cholerae of 
Koch). Non-sporogen- 
ous, flagellate, motile, 
parasitic, saprophytic, 
non-chromogenic aerobic 
and facultative anaero- 
bic, liquefying, spirillum, 
readily stained but Gram 
negative. 



Potential 
wealth loss. 



442 



MEDICAL DIAGNOSIS. 



Typical 
attack. 



lines, tending to spread from India, where it is endemic, to all parts 
of the civilized world. The great pilgrimages, fairs, and festivals 
serve to disseminate it widely; filth, over-crowding and infected water 
and food being part and parcel of such gatherings.* The disease is 
readily conveyed by fomites but is essentially water borne. The city 
of Hamburg in 1892-3 had 18,000 cases with a mortality of over 40%. 
Altona, a suburb, had but 516 cases, both cities drank the same water, 
but Altona filtered hers. One convalescent workman from Marseilles 
once infected the water of a large reservoir, and through it a large 
district of the city of Paris. Cholera is a hot weather and low altitude 
disease, the germ is readily destroyed by sunlight, but vast quantities of 
bacteria are discharged in the stools and many objects may serve as 
indirect carriers. It is not highly contagious and scrupulous care in 
regard to the dejecta permits nurses and physicians to perform their 
duties without fear of infection; indeed fear undoubtedly favors infec- 
tion. Age and sex seem to cut no figure as regards disease incidence, 
and neither absolute nor relative immunity is well proven. 

Morbid Anatomy. — Rigor mortis is extraordinarily rapid, producing 
horrible post mortem movements of the extremities, lower jaw and even 
of the eyes. The tissues are dry and shrunken, the blood is thick and 
tarry and there is an intense congestion of the stomach and intestines, 
and cloudy swelling and parenchymatous degeneration of the viscera. 

Symptoms. — The incubation period is from two to five days. 

Preliminary Stage. — This lasts but a few hours and presents malaise, 
marked mental depression, headache, diarrhoea, nausea, vomiting and 
colicky pains. 

Stage of Purging and Collapse. — This is characterized by profuse 
and almost constant serous discharges from the bowel, accompanied by 
tenesmus, intense thirst and excruciating muscle cramps especially 
affecting the abdomen and calves of the legs. Vomiting is almost inces- 
sant, the countenance is Hippocratic, cyanosed and shriveled, the skin 
is wrinkled, moist and cold, the superficial temperature is greatly sub- 
normal, though the rectal temperature may reach 103-105 F. 

The Blood. — There is both polycythemia and leucocytosis, the red 
cells running from 6,000,000-8,000,000 and the leucocytes from 14,000- 



* The British have found the utmost difficulty in checking its develop- 
ment and dissemination. Native visitors to Holy shrines bathe in Holy 
wells and drink of the precious water which contains the washings of many 
bodies. Sick and well are crowded together, dirt abounds, ventilation is 
deficient and in event of an epidemic the care of the sick and the proper 
disposition of the dead are alike neglected. 






THE INFECTIOUS DISEASES — PEST. 



443 



60,000 per c.cm. The hemoglobin percentage is high and the blood 
is obtained with difficulty. The pulse soon becomes excessively rapid, 
weak, flickering, or even absent at the wrist, the urine scanty or sup- 
pressed, the tongue and throat dry, yet the patient sweats profusely. 
The stools are 0} the characteristic "rice-water" type and the patient 
becomes comatose, or passes into the third stage. The duration 0} this 
stage of collapse is from a few hours to two days. 

Third Stage. — (Reaction.) All symptoms gradually subside and a 
tedious convalescence ensues Various late eruptions may occur. 

Prognosis. — The mortality varies from 25-75% m different epi- 
demics, death may occur in relapse, in cholera typhoid when the 
delirium is marked, and coma rapidly supervenes, or the patient may 
die even before the rice-water stools appear (Cholera Sicca). The 
so-called cholerine is a very mild form of the disease, accompanying 
certain epidemics and isolated cases offer great difficulty in diagnosis. 

Diagnosis. — In the absence of an epidemic, cases of poisoning by 
certain minerals, ptomains or mushrooms may cause difficulty. Cholera 
nostras (cholera morbus) in its severer forms exactly simulates true 
cholera. 

Positive Differential Symptoms. — (a). The agglutination lest, 
which is essentially the same as that for typhoid fever, is said to be 
positive as early as the second day. (b). The germ may be recovered 
and cultivated from the stools and the diagnosis thus absolutely estab- 
lished. 

BUBONIC PLAGUE.— ("Black death," "pest," malignant aden- 
itis). Definition. — A virulent epidemic infection caused by the bacil- 
lus pestis of Yersin, and characterized by high fever, great prostra- 
tion, the formation of buboes, a tendency to hemorrhage, both subcu- 
taneous and from mucous membranes, and a remarkably high leuco- 
cyte count, highly infectious but not markedly contagious. 

Historic Data. — It is as old as the Pyramids. After the 6th 
century it repeatedly visited Europe and Great Britain, killing during 
less than one century in London alone, 161,344 people, indeed, 
the epidemic of 1665 caused 68,000 deaths, the total population of 
London being at that time under 500,000. The Indian plague of 1889 
is said to have been responsible for at least 250,000 deaths and in the 
14th century it is said to have carried off not less than one-fourth of 
the total population of Europe. It is endemic in China and India. 
and a frequent visitor to the Philippines. 

Etiology. — It is distinctly a filth disease, requiring for iis proper 



An ancient 
scourge. 



444 



MEDICAL DIAGNOSIS. 



Readily 
conveyed. 



Difficult to 
control. 






Profound 
toxaemia. 



Buboes. 



Plague 
spots. 

High 

counts. 



Virulent 
types. 




Fig. 166. — Bacillus of Bu- 
bonic plague (bacillus 
pestis of Yersin). Mi- 
nute, non-motile, non- 
sporogenous, non-chro- 
mogenic, pleomorphous, 
aerobic and facultative 
anaerobic organism 
easily cultivated and 
stained but Gram nega- 
tive. 



development, dirt, over-crowding, poor food and a warm moist climate. 
The germ is an encapsulated, short, round micro-organism. Its habitat 
is the soil, and it may be conveyed by fomites, including food stuffs, 
such as butter, milk, cheese, green vegetables, by water or by sewage. 
It lives long and thrives in urine, sputum and fecal matter. Lice, fleas, 
flies and mosquitoes serve as carriers. Dogs, 
cats and rats become infected and serve as 
vehicles of contagion. These facts greatly in- 
crease the difficulty of stamping out an estab- 
lished epidemic. 

Morbid Anatomy. — That of an acute in- 
fection with profound toxaemia. The lymph 
vessels are chiefly affected, the glands being 
enlarged, edematous and hemorrhagic, or show- 
ing suppuration and external ulceration. The 
bacilli are generally distributed, the kidneys and 
spleen are hyperaemic and the lungs may show 
pneumonia and infarction. Primary and 
secondary carbuncles, ecchymoses and dermatitis 
may be present and the viscera generally show fatty and parenchym- 
atous degeneration with marked hyperaemia. 

Pestes Major. — Symptoms. — Incubation period 2 to 10 days. 
Prodromal period from 24 to 48 hours. Pallor, vertigo and profound 
muscular weakness are associated with nausea, vomiting and diarrhoea. 
Nose bleed is frequently present and mentaldepression marked. The 
fever rises steadily until just before the active stage. 

Active Stage. — This is characterized by cthill, high fever (104-106 
F.) and rapid pulse (120-200). The expression is anxious, countenance 
livid, conjunctives congested, the skin dry and hot. After three or four 
days buboes appear in from 70-80% of the cases. Those of the groin 
are affected primarily in 60% of the cases. Suppuration is a favorable 
sign, but gangrene may supervene. Petechia or extensive ecchymoses 
may appear (plague spots), as may other skin eruptions of various 
types. Any mucous membrane may be the seat of hemorrhage. 

The Blood. — The leucocytes average more than 90,000 to the c.cm. 
and there is marked polycythaemia, the average count of red cells 
being about 7,000,000 per c.cm. 

Varieties of Pestes Major. — (a). Sepiiccemic plague. In this 
form buboes do not appear, the organism is overwhelmed and death 
occurs in a few days or hours, (b). Pneumonic plague. In this the 



THE INFECTIOUS DISEASES— DENGUE. 



445 



lesions are chiefly and ordinarily those of broncho-pneumonia, the 
sputum is loaded with germs and about 90% of the cases die. 

Pestes Minor. — This mild form has slight fever of short duration, 
glandular swelling with or without suppuration, and may easily be 
misdiagnosed. Such cases are usually forerunners of epidemics. 

The Diagnosis. — Lacking an epidemic, the diagnosis must sometimes 
depend upon the recovery of the germ, as the agglutination reaction 
though often obtainable, is not absolute and occurs late in the disease. 
Reliance is to be placed chiefly upon (a). Prevalence of an epidemic. 
(b). Profound exhaustion, (c). Anxious countenance and mental depres- 
sion, (d). Buboes, (e). Petechia (f). Hemorrhage, (g). Leucocyte 
count. 

Pathognomonic Sign. — There is but one, viz.: — the recovery of the 
bacillus from the blood, urine, sputum or feces. 

Differential Diagnosis. — Tuberculous adenitis. Fever absent or 
intermittent, development slow and comparatively painless; this could 
hardly be confounded even with pestes minor. Syphilis presents initial 
lesion or cicatrices, sore throat, characteristic eruption of mucous 
patches and its buboes do not suppurate. Chancroid, initial lesion, 
strict localization of bubo. Hodgkin's disease and gonorrheal bubo 
could only be confounded with pestes minor by sheer stupidity or 
carelessess. 

The mortality is always large and even in those inoculated with 
antiplague serum it is said to be 14%. In some epidemics it runs from 

5o-95%- 

DENGUE.— (Deng-ga). ("Break bone" or "dandy" fever). Defi- 
nition. — A tropical and sub-tropical disease of low mortality and high 
infectivity, characterized by its sudden onset, severe muscular and joint 
pains, irregular rashes, double febrile paroxysm and tendency to relapse. 

Etiology. — It is probably due to an organism resembling the malarial 
Plasmodium, reported by H. Graham, of Beyrout, Syria, in 1903. 
The culex faligans or common mosquito of Beyrout is said to be the 
intermediary host and source of infection. 

Prognosis. — There is practically no mortality. Incubation period. 
Three to five days, no prodromata. 

Symptoms. — The onset is sudden with chill, high fever and rapid 
pulse, headache, backache, muscular, joint and deep seated bone pain 
associated with extreme tenderness. Both large and small joints may 
be swollen. Red and enlarged lymph glands are frequent, vomiting 
may occur, the face is deeply congested and a rash of short duration. 



Misleading 
form. 



Cardinal 
signs. 



Usually 
easy. 



Prognosis. 



A mosquito 
host. 



Arthritic 
onset. 



1 



446 



MEDICAL DIAGNOSIS. 



Remission. 



Terminal 
eruption. 



Severe 
forms. 



irregularly distributed, and variable in character is often present. 
One of the initial symptoms may be extreme pain in the eyes* On 
the second, third or fourth day a crisis occurs with the usual phenomena, 
and is followed by a period of remission of all symptoms, lasting from 
two to five days, then follows a reinvasion less severe than the first, 
terminating in a second crisis after three or four days or even 
a few hours, and during this stage a somewhat characteristic 
rubeolar eruption may appear, first on the hands, then over the body, 
but always most markedly over the hands, wrists, elbows and knees, 
occasionally forming a diffuse red rash by coalescence. Desquamation 
follows and is usually furfuraceous. A second remission and third 
paroxysm may occur, or the first remission may terminate the disease. 
In more severe cases, jaundice, black vomit, marked albuminuria 
and haematuria may occur and suggest "yellow jack." 

Differential Diagnosis. — (See yellow fever.) 

YELLOW FEVER.— ("Yellow jack," "bronze John.") Defini- 
tion. — A virulent infectious but non-contagious disease, characterized 
by sudden onset, high fever, jaundice, black vomit and slow pulse. 

Etiology. — Though the germ is undetermined, a commission, 
headed by the late Walter Reed, U. S. A., in 1900-01 proved the 
: intermediary host and infectious agent to be the mosquito known 
as the Stegoinyia fasciata. The work of this commission furnished 
one of the most brilliant examples of heroic self-sacrifice and 
scientific acumen in the history of medicine. Dr. Lazear became 
infected and died of the disease, non-immune volunteers slept for 
20 days in the stained sheets taken from the beds of yellow 
fever patients, their heads wrapped in soiled, bloody cloths, yet 
all these, being protected from mosquitoes, escaped the disease. Those 
isolated for long periods and then exposed to multiple inoculation by 
mosquitoes that had fed upon yellow fever patients, in nearly every 
instance developed the disease in its ordinary form. It was found that 
mosquitoes required 12 days to develop virulence, and retained their 
infectivity for 8 weeks or more. A subcutaneous injection of yellow 
I fever blood produced the disease even though the blood were defi- 
brinated and passed through a porcelain filter. The experiments 
proved that the only quarantine measures necessary were those calculated 
to destroy mosquito life in houses or on shipboard, and that the disease is 
not conveyed by fomites; further, that to control an epidemic it is only 
necessary to screen the sick and the houses of the well, destroy all resident 

* This may also be marked in yellow fever. 



Major 
Reed's 
great work. 



Heroism of 
volunteers. 



Period of 
virulence. 



Blood 
infective. 



Simple 

preventive 

measures. 






THE INFECTIOUS DISEASES— YELLOW FEVER. 



447 



mosquitoes and to treat marshes, stagnant pools, water barrels and other 
breeding places with petroleum which destroys the surface breathing larvoz. 
Through such measures, Santiago, Havana, and other towns were ren- 
dered free from yellow fever by the government medical authorities 
after the Spanish-American war. 

Seasonal Influences. — All that was previously written regarding 
these matters now resolves itself into a discussion of mosquito life and 
propagation and it has always been recognized as a summer and early 
autumn disease, killed by frost. Race. — The whites are chiefly 
affected, though negroes are not wholly immune and visitors con- 
tract the disease more readily than those acclimated. Sex. — There 
is equality of susceptibility, though on account of greater exposure 
males chiefly predominate. Age. — It resembles typhoid in its prefer- 
ence for the young adult. Old people and infants ordinarily escape, 
the latter probably from minimum exposure. Immunity. — One 
severe attack protects for life. 

Morbid Anatomy. — Diffuse nephritis, gastric hyperemia with hem- 
orrhagic stomach contents, hemoglobinaemia, general glandular enlarge- 
ment, cutaneous hemorrhages and deep jaundice are the usual findings. 

Symptoms. — The first stage strikes "like lightning from a clear 
sky," with chill and high fever (103-106 F.) accompanying a singularly 
slow pulse (80 to a temperature of 104 F.); there is excruciating pain in 
the loin and in the leg muscles, profound muscular weakness, violent 
headache, sore throat and vomiting, and the mental depression is often 
marked. A slight jaundice commencing in the eyes and extending to 
the chest, arms and body may appear even in this stage. 

Physiognomy. — The expression is thought by Guiteras to be quite 
characteristic. The cheeks and conjunctivce are congested, the eyes 
staring, humid and ferrety, the general expression "anxious." Album- 
inuria may be marked as early as the second or third day. There is 
photophobia frequently associated with intense orbital headache, vomit- 
ing, increasing in intensity until black vomit may appear; the tongue 
is swollen and beefy or often small and pointed, and the gums are tumid. 
The pulse is not only primarily slow, feeble and compressible but tends 
to decline even with rising temperature. 

Second Stage.— (From a few hours to 36 hours.) On the third or 
fourth day all symptoms abate leaving the pulse slow (even 30 or 40^ 
and compressible, the temperature may be normal and recovery follows 
in mild and favorable cases, though convalescence is often protracted 
and accompanied by irregular fever. 



Substantial 
proof. 



"A bolt 
from the 
blue." 



Early 
jaundice. 



Character- 
istic facies. 



Black 
vomit. 

Slow pulse. 



Re mission. 



448 



MEDICAL DIAGNOSIS. 



Falling 
pulse. 



Hemor- 
rhages. 



Renal 
symptoms. 



Relation to 
fever. 



Seldom 
offers real 
difficulty. 



Third Stage.— In severe cases a stage of intensification of the initial 
symptoms and collapse follows a remission. Its duration is from one 
to three days. The temperature usually rises slowly to 102 or 104 F. 
or may rise steadily until death, though the pulse may fall to 60 01 
even 30 beats per minute. The jaundice deepens, black vomit occurs, 
albuminuria is invariable, hematuria commences, total urinary suppres- 
sion is not unusual and hemorrhage may occur from the nose, gums, lips, 
rectum or any other mucous membrane, the skin may be of a deep 
mahogany color and various irregular eruptions may occur. The late 
Dr. West of Galveston always insisted that the renal symptoms over- 
shadowed all others in severe cases. 

Prognosis. — It is largely determined by the height of the original 
fever. In Sternberg's analysis of 269 cases, of those characterized by 
an initial temperature of 105-106 F., 61% died; of 104 to 105 F., 
30% died; of 103 to 104 F., 6% died; of 103 F., none died. Recov- 
ery may ensue in any case however severe, but convalescence is slow. 

Diagnosis. — Essential Data. Mild cases may be unrecognizable, 
but in marked cases one especially notes: — (a). Sudden onset without 
prodromata. (b). Presence 0} an epidemic or history of exposure, (c). 
Physiognomy, (d). Low initial pulse rate with high temperature, (e). 
Falling pulse rate and volume with rising temperature, (f). Excessive 
gastric irritability, (g). Early jaundice and later extreme pigmentation. 
(h). Black vomit, epistaxis and bleeding gums. (i). Albuminuria with 
a tendency to suppression (predominance of renal symptoms), (j). 
General tendency to hemorrhage, (k). The slight apparent loss of red 
cells per c.mm. is a marked feature in view of the hemorrhagic 
conditions. 

Differential Diagnosis. — Dengue, no mortality; joint symptoms 
usually more pronounced and persistent, yellow fever pulse-tempera- 
ture ratio absent; jaundice seldom marked and rarely as early as the 
3d day; black vomit usually absent, renal symptoms not so prominent 
or so early, rashes common and somewhat characteristic and hemor- 
rhages rare save haematuria. Malaria: Plasmodium malarice in the 
blood, sequence of phenomena usually widely different, enlarged spleen, 
response to quinine, renal symptoms less prominent, jaundice later, 
facies of yellow fever absent, albuminuria delayed and hemorrhage 
rare. Only the irregular forms of malaria can by any possibility be 
confounded with yellow fever. Acute yellow atrophy, Weil's disease 
or relapsing fever lack the chief symptoms of yellow jack. 

MALARIA. — (Marsh miasm). Definition. — An infectious disease 



THE INFECTIOUS DISEASES — MALARIA. 



449 



caused by the hcemamocba or Plasmodium malarias and characterized in 
its common forms by periodic paroxysms, consisting of chill, fever, and 
sweating periods, and, by its response to quinine. 

Historic Note. — One of the most ancient of diseases, malaria 
has been carefully studied in all ages, and when in 1880, a French 
army surgeon, Laveran, described its special organism, and Patrick 
Manson and Ross, a little later, demonstrated the role of the mosquito 
as intermediary host, it was found that little was needed to make all 
previously recorded and accepted observations fit the newer theory. 
Every one knew that the season of maximum prevalence of malaria 
was the spring, summer and early fall, that it prevailed most extensively 
in the tropics, that it tended to follow water courses and haunted the 
neighborhood of stagnant pools and fresh, brackish marshes, that salt 
marshes were free from it, and that sandy-bottomed fishy pools might 
abound without malaria. Its curious horizontal spread, the fact that 
dwellers in upper stories might escape it, the danger of night exposure, 
its rapid extension with the drift of prevailing winds, its disappearance 
under drainage and cultivation of land, all these things were thoroughly 
understood, even by the ancients, and each and every one corresponds 
to the life history of the mosquito. The carrier is the female anophe- 
les, wide prevalence, a mosquito never absent from malarial districts, 
although anopheles may be present in non-malarial districts, the 
organism being absent. The world wide distribution of malaria 
makes it a disease of great importance, although generally speaking 
of low mortality.* 

Characteristics of the Mosquito. — There are probably over 500 
varieties, the general appearance and character being too well known 
to require description. Like others of the order of Dipt era, they lay 
eggs from which come the larvae after two or three days of warm weather. 
These feed energetically on the water borne organic matter and are air 
breathers, a respiratory funnel being placed near the tail; hence they 
may be easily destroyed by the use of petroleum on the surface of their 
breeding places. The grown male insect is a vegetarian, the female 
seeks a mixed diet and sucks the blood, not alone of man, but of mam- 
mals generally, and, it is said, of birds, reptiles and even of fishes. The 
time required for full development is about 30 days in warm summer 

* Fifteen thousand aresaid to die annually of malaria in Italy. It has been 
estimated that over ^,000,000 cases occur annually in Russia. Japan. India, 
China and tin- Philippines suffer greatly ami the yellow races seem to have 
little or none of the immunity so evident in the Congo-black or pure negro, 
the Japanese, Chinese and East Indian being readily infected. 
29 



Mosquito 
intermedi- 
ate host. 



Conditions 
governing 
incidence. 



Air breath- 
ing larvae. 



Easily 

destroyed. 



^ 



45° 



MEDICAL DIAGNOSIS. 



Dark colors 
attract. 



weather and the hatching process may be repeated several times dur- 
ing the season, one pair of insects producing millions of their kind. 

The Special Characteristics of the Anopheles.— Length of palpi 
and proboscis about equal, the former four-jointed in the female and 
three-jointed in the male. The straight filamentous palpi are held 
parallel with the proboscis, the wings are often spotted, the abdomen 
is pilose with no scales, the legs are long, ending in dentate claws and 
the nucha has posterior scaly cornu. 

Color in Relation to the Mosquito. — Nuttall has reported some 
interesting observations in regard to the color preferences of mos- 
quitoes. He found that of the various colors ranging from white to 
black, the former was the least, the latter the most attractive. The 
observations are of distinct value in relation to the proper colors for 
clothing for dwellers in mosquito infested communities. 

Classification of the Organism. — As will be seen from the plates, 
the malarial organism -is easily recognized and differentiated by blood 
examination and the expert observer can also closely predict the time 
of segmentation and recognize double or triple infection. The divi- 
sions correspond to the old clinical periods based upon the frequency 
and regularity of the seizures. The tertian organism, requiring 48 
hours for its development brings about a paroxysm on each third day, 
the interval of apyrexia being one day. The quartan, requiring 72 
hours for its development, causes a paroxysm on each fourth day, with two 
days of apyrexia. If two tertian organisms are developing, the paroxysm 
assumes a daily type; in the case of double quartan infection, attacks 
appear on two successive days leaving one day of apyrexia. If as 
rarely happens there be a triple quartan infection, the disease assumes 
the quotidian or daily type, as in the case of the double tertian. 

Estivo-autumnal Plasmodium. — This is irregular in its develop- 
ment and manifestations and is the variety which causes the severer, 
more chronic, malignant, or pernicious types of the disease. In the 
United States the tertian organism is exceedingly common; the quartan 
rare. The accompanying plates give a description of the various forms 
and show their progressive development at the expense of their erythro- 
cyte host. 
Examination of the Blood for Malarial Organisms. — Fresh blood 
Fresh blood on a warm stage gives the most satisfactory results in these examinations, 
but it is quite possible to detect them in the dried and fixed specimens, 
stained as in ordinary blood examinations. If the old triple stain be 
used, or the better stain of Wright, already described on page 380, 



Tertian 



Quartan. 



Double 
infections. 



Quartan 
rare. 



best. 



^ 



DESCRIPTION OF PLATE III. 



Quartan: — i, 2, 3, 4, 5 and 6, show the development from the hya- 
line form to the mature intracellular (6) and large extracellular (10) 
forms; 11 shows vacuolization of an extracellular form; 7, 8, 9, show 
segmentation stages; 12, the flagellate form. 

Note: — In the tertian and aestivo -autumnal organisms the same 
phases are shown. 

Note : — 

A. Relative depth of color in the erythrocyte host, deepest in the 

quartan, lightest in the tertian. 

B . Comparatively coarse, scant and dark granules of the quartan as 

compared with the tertian. 

C. Tendency to shrinkage in the erythrocyte host of quartan vs. large 

pale host of tertian. 

D. Peripheral arrangement of pigment in developmental stage of ter- 

tian and quartan followed by central grouping initiating segment- 
ation. 

E. Note greater regularity in quartan as compared with tertian forms. 

F. Note relative number of segments. 

G. Note greater density and clearer outline of quartan forms. 

H. Star-like arrangement of pigment in early segmentation stage of 
quartan. 

I. Relatively small flagellate forms of quartan and aestivo-autumnal. 

J. The peculiar ovals and crescents of the developed aestivo-autum- 
nal form, its scantily pigmented spherical form (35) and the 
ring bodies of the early stage. 



PLATE III. 



THE QUARTAN PARASITE 



% mm 



12. 



m;* 



\ . — 



ff{5 f 



THETE 


KTIAT^ 


J PARASITE. 


i?> 14- 


15 


16 17 16 


19 Z.O 


Zi 








■t-i?'"' ~~ " 



THE ^S WO AVTUMNAL PARASITE. 


23 


24 2,6 


26 


2.7 


28 








i 


1 


2<> 
53 


SO 3f 

• 


32 
> 


33 

I 
37 


34 


| 


: ; S 




{jfc-?' 


"" ^N 



THE INFECTIOUS DISEASES— MALARIA. 



451 



the organism will be found to have taken the blue. The common 
mistake born of inexperience lies in the failure to search primarily for 
pigment, and in the readiness with which the unpigmented forms are 
confounded with artefacts. In nearly all specimens taken at a proper 
time pigmented organisms may be found within the erythrocytes and 
pigment granules in the leucocytes. In the tertian variety the pigmented 
forms appear from 8-16 hours after the preceding chill, and the large 
pigmented organism is best obtained 8 hours before the paroxysm. It 
is useless to hunt for tertian or quartan forms if quinine has been taken 
for 24 hours or more. 

Symptoms. — The tertian and quartan forms are manifested by 
typical paroxysms whatever the frequency of their occurrence, and 
the order of events is as follows: — (a). The cold stage: — after a rigor 
lasting form \ to i\ hours and occurring usually in the mid forenoon 
or early afternoon, the temperature, which rises with and during the 
chill, reaches a maximum (104-107 F.) and the cold stage is succeeded 
by (b) the hot stage which presents all the symptoms of sthenic fever 
which reaches its fastigium in an hour or two and declines to normal 
during the next 6-8-10 hours, its recession being marked by the com- 
ing of (c) the sweating stage during which all symptoms abate and 
the patient feels well. These attacks vary greatly in duration, those 
of the severe type lasting from 8-14 hours. The spleen enlarges if 
they are repeated on several days, and if long continued tends to become 
permanently hypertrophied (ague cake). In spite of the marked 
evidences of infection there is a normal leucocyte count or more fre- 
quently a leukopenia. Herpes labialis is a common manifestation, 
albuminuria may be present during the attacks or persist if they are 
frequently repeated, and the gastro-intestinal disturbances accompany- 
ing the fever may be profound. The estiva-autumnal form, due to the 
organism of that name, may at its onset be definitely periodic, usually like 
tertian but with longer paroxysms. Ordinarily, owing to the irregular 
development of the parasite crops, the fever tends to assume the remit- 
tent (bilious remittent) type and in such cases the temperature curve 
may be lower than in the fastigium of the regular form. Jaundice is 
common, gastrointestinal symptoms and splenic enlargement marked. 
Under this head the most diverse types of malaria must be included, 
representing on the one hand the larval types, or dumb agues often 
manifesting themselves by persistent headache, neuralgia, general 

malaise, dyspepsia, anaemia, etc., and at the other pole the pernicious 

form ol the disease encountered especially in the tropical and sub- 



Look for 
pigment. 



Best time 
to search. 



"Fever 
and ague." 

Cold stage. 



Hot stage. 



Sweating 
stage. 



"Ague 
cake." 



Herpes and 
albumin- 



Tertian. 



" Dumb 
ague "' 
sequelx. 



^ 



452 



MEDICAL DIAGNOSIS. 



Choleraic 
and coma- 
tose forms. 



Black- 
water 
fever. 



Usually 

estivo-au- 

tumnal. 



Misleading 
symptoms 



Blood ex- 
amination 
and thera- 
peutic test. 



tropical countries. These assume various types, are often limited to a 
certain small area and are peculiarly fatal in the unacclimated. 

Classification of Pernicious Forms. — (a). Choleraic. Symptoms, 
low or slightly elevated temperature, vomiting, choleraic diarrhoea and 
stools, frequently a jaundice, cyanosis, feeble, rapid pulse, collapse and 
high mortality, (b). Comatose form. Usually preceded by a typical 
malarial paroxysm which is succeeded by stupor, hyperpyrexia, Cheyne- 
Stokes breathing and every symptom of collapse, stupor deepening 
into coma. (c). The hcematuric or hcemoglobinuric form. This is 
characterized by the predominance of renal symptoms, associated at 
times with bleeding from the mucous membranes and includes undoubt- 
edly the so-called "black-water fever." It is very fatal. 

Comment. — These pernicious forms are usually though not invariably 
associated with the estivo-autumnal organism; in the choleraic type 
masses of organisms may be found in thrombi of the intestinal vessels ; 
in the cerebral or comatose form, in the vessels of the brain. The 
strong resemblance to yellow fever presented by these cases will at 
once be noted. 

(For differential diagnosis see yellow fever.) 

Chronic Malaria. — (Malarial cachexia). The chief characteristics 
of this form are the enlarged spleen, anaemia, sallow skin and persistent 
malaise. In many instances there is a tendency to chronic diarrhoea, 
dysentery or marked chronic gastro -intestinal disturbance of a vague 
and indeterminate type. In some cases there are accessions of fever, 
perhaps actual paroxysms occurring irregularly, and persistent and 
repeated examinations will usually reveal the estivo-autumnal organ- 
ism. Complications. Persistent neuralgias, often regularly or irregu- 
larly periodic, persistent anaemia, gastro-intestinal difficulties and 
chronic nephritis are among the commoner complications and, more 
rarely, actual changes in the brain, spinal cord or peripheral nerves may 
occur, producing paralysis, ataxia or even symptoms of disseminated 
sclerosis. 

Diagnosis. — The recognition of the regularly periodic form is not 
difficult but in general no accurate diagnosis can be made without an 
examination of the blood, the two elements of importance being the 
Plasmodium and the leukopaenia. Clinically dependence must be placed 
oftentimes upon the effect produced by quinine given in large doses 
and in solution. The differential diagnosis as regards typhoid and 
yellow fever has been discussed under those diseases. 

RELAPSING FEVER.— Definition.— An acute contagious disease 



DESCRIPTION OF PLATE IV. 



Malarial Organism of types shown in plate but treated with Wright's 
stain. 

Quartan Parasite. 

i. Non-pigmented form. 

2, 3, 4. Young organisms showing chromatin bodies (red) and pig- 
ment granules. 

5, 6. Full grown parasites, the former intracellular, the latter ex- 
tracellular. 

7, 8. Presegmentation forms. 

9. Segmentation. 

n. Normal blood cell. 

12. Flagellate body. 

Tertian Parasite. The forms are self explanatory in connection 
with the preceding description. 

iEsTivo-AUTUMNAL Form. Various ring forms are shown together 
with the characteristic crescents, Nos. 32, ^, 34. 

(In both this and the preceding plate the drawings are almost en- 
tirely based upon personal observation, though certain forms have 
been adapted from Thayer's valuable monograph.) 



PLATE IV. 

THE QUARTAN PARASITE 



i 2V 


3 


4 


5 


6 


j0m&. ^M^ 


^^^ 


^■■"^ 


. •••••?•, 


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a < • " 






* v'; 4 :>* 


''•*::••' •'-•: :/ 


7 3 


a 


lO 


11 


12 




#1 

(3*ifeY 






,.:-.. 
(?*? 





THETEETIAN PA 


w 


^srm 




13 


14 


15 ie 




17 


io 


13 


20 


21 


/ 


\ 22 


& ,:•;•' ' 


U *•'*!«' 


^*\ / * * ■ ', 




( ■' 

S 







THE v€,5TIV0-AVryVD\ALPAI^5rni 



25 


24 


2 5 £6 


27 


2ft 


Q 


• 


% #^ 




i'/.\. '*•*' 


23 


» . • 


30 31 32 


33 


.. 34 




« < 


' I* ask • **•• 




■••"*■. 


35 




? S - 


37 


9=^ 



THE INFECTIOUS DISEASES— TYPHUS. 



453 




Fig. 167.— Spirillum of 
relapsing fever (spiro- 
chaeta Obermeieri). Mo- 
tile, flagellated, spirillum 
readily stained but not 
cultivated and Gram 
negative. The organism 
is usually longer than 
as shown in the illustra- 
tion. 



due to the spirochaeta Obermeieri, characterized by recurrent febrile 
paroxysms, each being of from 5-7 days, duration and associated with 
an acute onset and critical termination. Etiology. — The disease is 
one of filth and is highly contagious. The spirillum is unquestionably 
the cause of the disease but cannot be cultivated. Morbid Anatomy. 
— There are no special lesions, enlargement of 
the liver and spleen being common, together with 
catarrhal inflammation of the gastro-intestinal 
tract. Symptoms. — The symptomatology is 
summed up in the definition. It represents re- 
peated attacks of high fever of sudden onset 
terminating by crisis, alternating with afebrile 
periods of about the same duration. The diag- 
nosis is at once established by an examination 
of the blood which reveals the long spirilla 
which are in length about three times the 
breadth of the red cell. The usual complica- 
tions of fever of this type may be present, i.e. 
pneumonia, nephritis, hyperpyrexia, jaundice, 
ophthalmia, and renal, gastric, or intestinal hemorrhage, yet in general 
the disease is uncomplicated and the prognosis favorable. 

TYPHUS FEVER.— ("Spotted fever," "ship fever"). Definition. 
— An acute self limited infection characterized by sudden onset with high 
and continuous fever, terminating by crisis on or about the fourteenth 
day, and associated with a petechial eruption and a mottled skin. 

Historic Note. — This ancient disease was confounded with typhoid 
fever until the early part of the nineteenth century, and even the clear 
distinction made by Louis did not bring about its separation from typhoid 
until nearly half the century had passed. Once a common and fatal 
disease, it has now become one of the rarest and is limited to unsanitary, 
semi -civilized and densely populated countries or communities. Over- 
crowding, bad air and dirt have always been its chief promoters. It is 
highly infectious, but its micro-organism is unknown. 

Morbid Anatomy. — There are no characteristic changes beyond 
those of an intense febrile infection. 

Symptoms. — The symptoms characteristic of typhus fever arc 
the onset of high temperature of a continuous character, preceded, or, 
at the outset accompanied, by chilling or actual chills with marked 
headache, backache, prostration and the rapid development oi a typical 
"typhoid state," but the eruption is darker than in typhoid, and though 



A banished 
scourge. 



454 



MEDICAL DIAGNOSIS. 



first appearing on the abdomen spreads over the whole body surface' 
and is accompanied by a curious mottling of the skin. The term- 
ination is usually but not invariably by a sharp crisis, relapse is rare 
and the complications are those attending any profound febrile infection 
with marked toxaemia. 

Prognosis. — The mortality may reach 50% in old people, and 
varies from 10-20% in children and young adults. 

MALTA FEVER. — (Mediterranean fever, undulant fever, "rock 
ever," Neapolitan fever, Gibraltar fever). Definition. — An endemic 



Confers 
immunity. 



DAY OF 
DISEASE 


L 2 


3 


4 


5 





7 


3 


9 


10 


11 


12 


13 1 


4 15 


16 


17 


18 1 


9 20 


21 




HOUR * 


P A P 
M M M 


u 


P 


A f- 


as 


H 


, 


M 


P 

M 


A 


M 


M 


P 

u 


M M 


H H 


M* 


M ! MM 


p a!p 

M M M 


M M 


± 


£!£: 


£± 


i 


p 












































































































































































































































































































































































































































































































































































1 " — 




















































— ) 
















— 


















































-P 
















- 105 - 


























































































































































































































































































































































— 














- 4U B 

= > 
C 

—39 S 
c 
























































































































































































































































































































































































































































































































































W 101 - 








































































































oJ9 

—38 3 

c 




















































































































































































































































































































































































































































































































-, 


















































































































































9#- 


















/» 








































' 1 — 


— \ — 


■ 






" 


, _ 







































: 








































































































































































































































































































































































9G - 


































































— L 
















— - 





































Fig. 



-Clinical chart of relapsing fever showing the febrile movement upon the 
fourteenth day.— (From Wilcox's Fever Nursing.) 



infectious fever due to the micrococcus melitensis {Bruce) and character- 
ized by long continued undulatory pyrexial periods and repeated relapses. 
Etiology. — The micrococcus melitensis, discovered in 1887. is a small 
oval or round coccus, staining readily though not by Gram's method, 
easily cultivated in bouillon, in agar-agar or gelatine, and showing an 
agglutination reaction similar to that of typhoid fever. By accidental 
inoculation, as well as by actual experiment, the specific action of the 
germ has been amply proven but the exact method of its dissemination 
is unknown. It is essentially a disease of summer, respects no age, is 
uninfluenced by sex and confers prolonged immunity. 



TFIE INFECTIOUS DISEASES — MALTA FEVER. 



455 



Morbid Anatomy. — The pathological changes are not specific; 
there is general visceral congestion affecting the lungs, which in 
some cases show actual consolidation; the heart muscle shows 
degenerative changes, the liver and spleen are enlarged and in 
chronic cases show a fibroid change. There is moderate anaemia, 
and often a relative leucocytosis, the spleen contains the specific germ 
in quantities and shows an increase of lymphoid tissue. 

History. — Unrecognized or at least undifferentiated, this disease 
has no doubt existed from time immemorial, along the shores of the 
Mediterranean and ancient writers are supposed to have referred to it 
under the head of malaria. Various observers have reported it in a 



DAY OF -I 

DISEASE A 


2 3 4 5 


G 7 


8 


9 10 11 


12 


13 




HOUR m m M 


M M [ M M H M 


M M M £ 


M M 1 


M M H M 


i M M 


H 1 




















































































































106 






















:_d_J: 








rr 105 -- 


11 " 7 


V, 


A 


= *| 


:zz 


~ 




■o < — 


fS\ I 


vV 


w 












... 










g wi—j 


3-V-tA 


_i_ii_ 






















« ~3 


! V 






















b 103° : - : 


! -- 





.7.7. 1 


















3 <~= : 

§ 102 - - 






1 














\ 





















^ Wl= = 

a, 


= 3====: 


:===: 




\ 


-- 






3 100 


L___ — L 


MT 




\ 


-t- 






99" 


- - 


:---: 




77j7.tr 


v - 


.. : 






= i===: 


:~z3 


:=p 


777 777 Z 


SA 


r 




98 


EE§ 


- 4- - 








V 




97 - '■ 


=¥==1 


EztzL 


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:!=-!- = 


--!-- 


- 




96=- 


"1 T 


:==3 


:z~i 


z\— zt z 


— L 






■ 








L . 





Fig. 169.— Clinical chart of typhus fever ending in recovery. 
—(From Wilcox's Fever Nursing.) 



more recent period and it would seem to be widely distributed, cases 
having been reported from the East and West Indies, from Centarl 
America, and even in this country in isolated instances. 
Period of Incubation.-— The incubation period is from three days 

to three weeks, lasting on the average from ten to fourteen days. 

Symptoms. The onset closely resembles typhoid, the fever running ., 
J r _ - ' ■ Resembles 

in waves of three weeks' duration, repeated once, twice or many limes typhoid. 

with intervening periods o\ normal temperature, li may last for from 



456 



MEDICAL DIAGNOSIS. 



two or three weeks to two years, its average duration being about three 
months. As a rule, the first relapse is more severe than the original 
attack, being associated with chills, high intermittent fever and a diar- 
rhoea which replaces an antecedent constipation. 

Differential Diagnosis. — From malaria it is differentiated by the 
absence of the specific haemamceba of that disease. From -typhoid by 
the failure of the agglutination test of Widal. Aside from these pro- 
cedures one must depend simply upon the differences in the general 
symptomatology, the temperature chart and the tendency to distinct 
relapses. 

Prognosis. — Oddly enough, the disease furnishes but 2% mortality, 
the loss of time, the discomfort and interruption of affairs being the 
chief inflictions. 

MILK FEVER.— (Milk sickness). This is a rare and frequently 
fatal disease limited to the southern and western part of the United 
States and is apparently derived from the ingestion of the uncooked 
flesh or milk of cattle suffering from " trembles." 

Symptoms. — A short period of malaise is followed by vomiting and 
epigastric pain, fever, constipation and muscular tremors. The symp- 
toms closely resemble ordinary ptomaine poisoning, and there may be 
active or typhoidal delirium, coma or convulsions. 

MOUNTAIN FEVER.— There is no single disease to which this 
term may be properly applied. Most of the cases so denominated by 
the earlier writers were unquestionably unusual forms of typhoid fever. 

MILIARY FEVER.— (Sweating sickness). In ancient times this 
disease was extremely prevalent and fatal throughout all Europe, but 
is now seen only in limited districts of Italy, France, Austria, Asia 
Minor, Germany and Switzerland. Following a short period of malaise 
the onset is marked by drenching sweats, persistent and recurrent, 
with from seven to ten days of high fever, and on the third day an erup- 
tion consisting of miliary red papules and tiny vesicles. 

FOOT AND MOUTH DISEASE.— This is merely a severe epidemic 
aphthous stomatitis due to eating the flesh or milk of cattle affected 
with the disease of the same name. It is extremely rare, but furnishes 
a considerable mortality (10%). 

FLOOD FEVER. — (Japanese river fever). This is a rare disease 
limited to a small area of the Island .of Nippon, and afflicting only 
workers on the inundated land; amongst these it spares neither age 
nor sex. Its exact cause is unknown and it has no specific morbid 
anatomy. 



THE INFECTIOUS DISEASES— MEASLES. 



457 



Symptoms. — Ulcers in the axilla, groin or neck, associated with 
repeated chills, continued high temperature, moderate lymphatic involve- 
ment and profound toxaemia. A coarse papular eruption appears on 
the sixth day and disappears promptly after several days. 

Prognosis. — The duration of the disease is from two or three weeks 
and the mortality varies greatly, running from 10-80% in different 
epidemics. 

KALA AZAR. — (Black fever). This curiously obscure and deadly 
disease has for some years prevailed in a limited district of Assam, 
having commenced its onward march at Rungpore in 1887. It extends 
along lines of communication at the slow rate of 14 miles a year, its 
visitation lasting for five years and the natives believe that one year is 
required to render safe any house in which it has appeared. It spares 
no age and neither sex, and what is more peculiar attacks the acclimated 
quite as readily and violently as the stranger. Its mortality is frightful, 
being put at 96% by Manson, and its victims may linger on for a year 
or more. 

Etiology. — The causative factor is unknown. It has been regarded 
as malaria, uncinariasis, modified Mediterranean fever and trypan- 
osomiasis.* 

Symptoms. — The high fever, often preceded by vomiting or chill 
may assume either a remittent or intermittent type, lasting one, two, 
four or six weeks; then follows an apyrexial period, then an exacerba- 
tion, and so on for months, when the fever becomes persistent though 
remittent and profuse sweats characterize the remissions. Emacia- 
tion is extreme, liver and spleen enlarge early, profound anaemia 
supervenes, and a dirty gray pallor and brittle dry or falling hair add 
to the striking clinical picture. 

Termination. — The patient dies ordinarily from an intercurrent 
pneumonia, dysentery or exhaustion. 

MEASLES.— (Morbilli). Definition.— An acute highly contagious 
febrile exanthem of childhood of unknown causation, conferring im- 
munity, and characterized by marked catarrhal symptoms of the 
respiratory tract and a peculiar eruption. 

Etiology.— Children under 12 years of age are remarkably sus- 



A ghastly 

clinical 

picture. 



*The disease in many respects Lends itself to each theory, though the 
fad thai agglutination of tin- micrococcus melitensis has been shown by 
Bentley's work would seem to strongly support the Malta fever theory. 
The observations by Rogers made during the last year are interesting bul 
not conclusive. 



45» 



MEDICAL DIAGNOSIS. 



Few 

escape 
contagion. 



Important 

fever 

curve. 



Character 
and distri- 
bution. 



Desqua- 
mation. 



ceptible,* and the winter and spring are its chief seasons. Con- 
tagiousness. Practically every exposure in children under ten results 
in an attack and as it spreads by proximity, contact and fomites, and 
unfortunately in both the early and later stages (diminishing only 
with established convalescence), few children escape infection and its 
virulence increases with the age of the person attacked. The 
mortality is terrific amongst the poorer tenement classes but in 
private practice it should not exceed 5% amongst well nourished 
children, f 

Morbid Anatomy. — Merely that of the complications and catarrhal 
inflammation of the respiratory tract. Incubation one to two weeks, 
usually eight to twelve days. 

Symptoms. — The presence of a marked coryza, injected conjunctives, 
photophobia and indications of slight fever may be the only signs noted 
at the onset. Chill or decided chilliness is less common. 

Fever. — The fever rises steadily, reaching its maximum (103-105 
F.) with the appearance of the exanthem (4th day). Its subsidence 
begins as the rash commences to fade, and the normal is attained, 
either by crisis or a lysis occupying from two to four days. 

The Rash. — White tipped, red spots (Koplik's. spots) on a congested 
buccal or labial mucous membrane appear early in 90% and the mucous 
membrane may show the true eruption before the skin is affected. J 
At the end of the third or during the fourth day, and at the height of the 
fever, the general rash becomes manifest as a dusky mottling, becoming 
more distinctly red though still dusky, and at the end of 24 hours (fifth 
day usually) palpably papular and " shotty ." It appears first at the 
margins of the hair and in the region of the ears and the forehead and 
gradually spreads over the forehead, neck, face, chest, trunk and lower 
extremities, often assuming a crescentic arrangement and reaching its 
acme and fading in its first location before reaching its maximum in the 
later ones, so that cases are likely to present rashes of varying stages 
of development in the different portions of the body. Desquamation, 
fine and branny follows and lasts for about one week. 

Duration of Stages. — Period of incubation, 1-2 weeks. Period of 

* Continued prevalence seems to confer a partial immunity for the 
disease is terribly fatal when introduced into countries previously exempt. 

t In favorable climates much less. 

+ Koplik's spots are rose red with a punctate bluish white centre tending 
to spread and multiply as the disease progresses and giving place to general 
redness and a multitude of spots at the time that the general body erup- 
tion is developed. 



THE INFECTIOUS DISEASES — PAROTITIS. 



459 



invasion, 3-4 days. Period of developed rash, 1 week. Period of 
desquamation, 1 week. 

Complications. — Broncho-pneumonia is the most common and 
serious one, causing death in 30-40% of such cases in the public 
services, and even in private practice furnishing a heavy mortality. 
The disregard of this disease manifested by the laity is deadly in its 
effect, as children are exposed to pneumonia and other complications 
from sheer ignorance of its high mortality.* Broncho-pneumonia 
is an especially deadly complication in sucklings. Severe conjunc- 
tivitis and keratitis occur especially, often in those poorly nourished 
and badly cared for, and the same may be said of severe gastroin- 
testinal disturbance, stomatitis or even gangrenous processes. The , 
eyes may remain sensitive for a long period. Pertussis is frequently 
associated with measles, tuberculosis is a not infrequent sequel, and 
the milder degrees of otitis media and affections of the nasal structures 
are not infrequent. The Urine. Transient albuminuria is not uncom- 
mon, and Ehrlich's diazo-reaction is invariably present. Blood: — 
Leukopenia or a normal count is the rule. 

Diagnosis. — The combination of a febrile period of three full days 
associated with marked coryza, Koplik's spots and the peculiar eruption 
serve to distinguish the disease from drug and serum rashes and rubella. 
The temporary measle-like rash of the preliminary stage of smallpox 
must always be borne in mind. Great variations in the disease exist; it 
may be trivial or virulent, febrile or afebrile, with a very slight or absent 
exanthem. The eruption may be hemorrhagic (black measles) and 
cases may, from the start, show predominance of nervous or pulmonary 
symptoms and the lungs should be examined carefully, at every visit. 
A case of persistent measle-like rash may prove a syphilis. 

MUMPS. — (Parotitis, epidemic parotitis). Definition. — An acute 
epidemic, infectious, immunity conferring, highly contagious but usually 
trivial, disease of childhood of unknown causation characterized by inflam- 
mation of the parotid gland and mild systemic symptoms. 

Etiology. — Children under four and adults are but slightly suscep- 
tible. The disease is transmissible in any stage, by contact, contiguity 
or fomites. 

Incubation Period. — 48 hours to three weeks. Duration. Active 

symptoms about one week, gradual subsidence. 

*The public services o{ the greal cities furnish shocking examples, and 
tin- author remembers a little girl who was found living of broncho-pneu- 
monia facing the bright sunlight with two eyes whoso corneas had molted 

away like mist. " She had but a touch of measles," said the mother 

3° 



Important 
data. 



An under- 
rated ail- 
ment. 



Sucklings. 



The eyes. 



Diazo. 



Look out 
for small- 
pox. 



Syphilis. 



Highly 

contagious. 



460 



MEDICAL DIAGNOSIS. 



Adults 
chiefly. 



Ovaritis. 
Orchitis. 

Mastitis. 



Hospital 
cases. 



Age, phy- 
sique and 
climate. 



Abrupt 
onset. 



High initial 
fever. 

Early rash. 



Morbid Anatomy. — An acute parenchymatous inflammation of the 
parotid gland. 

Symptoms. — Pain and swelling, usually bilateral, but often single, 
in the parotid region. Fever usually mild (102 F.) and of short dura- 
tion. Dry mouth, intolerance oj acids. 

Complications. — In the comparatively rare cases in adults unilateral 
or rarely bilateral orchitis is a frequent complication (20-30%), though 
rare in children. Suppuration of the gland by infection through Stenon's 
duct is a rare development. In the female, ovarian congestion or 
inflammation or painful swelling of the breasts may, rarely, be found. 

SCARLET FEVER.— (Scarlatina.) Definition.— An acute infec- 
tious and highly contagious fever of children of unknown causation, con 
f erring immunity and characterized by a sudden onset, the prompt appear- 
ance (second day) of a punctate bright scarlet exanthem, terminating in 
desquamation and showing a marked tendency to inflammatory involve- 
ment of the kidney, middle ear, throat and cervical glands. 

Etiology. — The disease is conveyed chiefly by direct contact and 
fomites, less often by proximity, the secretions being, according to late 
investigations, more potent than the desquamated scales. In hospitals 
severe and complicated cases should be kept away from the mild and 
uncomplicated. It attacks chiefly children under 16 years, but adults 
enjoy only a relative immunity. 

Prevalence. — It prevails throughout the year, but chiefly in the 
autumn and early winter months and covers nearly the whole globe. 
Mortality. — The general mortality varies from 10-15%, an d i* 1 
children under 6 years of age, it may reach 25 or 30%. As in other 
diseases of this group the mortality varies greatly in private as com- 
pared with public service practice, and in weaklings as compared with 
the sturdy. A damp cold climate seems to increase the severity and 
frequency of complication, and hence the mortality. 

Symptoms. — With or without antecedent malaise there is (a) an 
abrupt onset, usually marked by vomiting with or without nausea, 
and commonly with sore throat, indeed the latter symptom may be 
dominant, (b). Fever, 100-105 F. at onset, diminishing by lysis with 
the complete development of the rash and reaching normal in a week or 
ten days, unless complications occur, (c). The rash. This appears in 
i from 12 to 24 hours, first on the chest, and spreads with great rapidity. 
It is really punctate, the color being deepest about the hair follicle, 
but it appears diffuse and is commonly described as a lobster-like redness 
which spreads over the whole body in a few hours. As in every other 



THE INFECTIOUS DISEASES — SCARLET FEVER. 



461 



eruptive fever, it varies greatly in intensity, in some cases escaping 
superficial observation. It should be remembered that it is most 
intense about the flexor aspect of the joints, the groin and inner aspect 
of the thighs, and on the anterior surface of the upper chest. In marked 
cases it is unmistakable and the fact that about the upper lip it is often 
almost absent gives a characteristic fades. It fades in from three or 
four to seven or eight days and a remarkable desquamation follows, quite 
unlike that of measles. The skin- peels and may come away in large 
sheets. Exfoliation may be complete in a few days, or last for three 
or four weeks, and the scales are infectious, though probably less so 
than has been believed. The order of desquamation is usually, 
chest and neck, 4th-7th day; hands I2th-i4th; feet i4th-2ist. (d). 
Rapid pulse. Excessive rapidity may be present before the appearance 
of the rash and persist throughout the active stage, (e). Strawberry 
tongue, light, white or grayish furring punctuated by red and promi- 
nent papillae is a somewhat prominent feature. 

Complications . — The danger in scarlet fever lies in Us complications 
and of these nephritis is most to be dreaded. This when present takes 
the form of an acute nephritis, developing usually at the end of a week. 
Mere febrile albuminuria is common and sharp congestion may occur 
and promptly subside. A hard pulse should direct attention to the 
kidneys, the urine should be measured and a specimen examined at least 
once in 24 hours* and the patient should be carefully guarded from 
exposure to cold and wet for some time after the disappearance of all 
active symptoms of scarlatina. 

Suppurative otitis media is another dangerous complication, re- 
sulting oftentimes in mastoid abscess, septic meningitis, general sepsis 
and permanent deafness. The throat should be kept as clean by sprays 
and gargles as the circumstances permit, and the ears should be watched 
carefully, especially in infants. Swelling of the cervical glands is common 
and may result in extensive infiltration and suppuration. 

Pharyngitis and Tonsillitis. — These may be extreme and a true 
or pseudo-diphtheritic membrane may be present. The occasional 
coincidence of scarlatina and diphtheria is not to be forgotten. Endo- 
carditis, pericarditis and myocarditis frequently result and the heart 
should be carefully auscultated at each visit. Parotitis, septic arthritis, 
broncho- pneumonia, lobar pneumonia, pleuritis and empyema arc rare 
Complications but active delirium and even convulsions may be present. 



Points of 
election. 



Peculiar 
facies. 



Lamellar 
peeling. 



Rapid 
pulse. 
Strawberry 
tongue. 



Xephritis. 



Safe- 
guards. 



A cause of 
deafness 
and men- 
myitis. 



Diphtheria. 



Other com- 
plications. 



*The early administration of urotropin, and the 
cream should' diminish the frequency of this dreaded 



free use of Vichy ami 
complication. 



462 



MEDICAL DIAGNOSIS. 



~^r : / 

Diagnosis. — Sudden onset, vomiting, fever, sore throat, a typica 
rash and a rapid pulse are unmistakable, but many cases arise which 
tax the resources of the cleverest clinician. Doubtful rashes may be 
made plain by the hot pack or hot bath. Excessively rapid pulse is 
important in connection with other suggestive symptoms. The hard 
pulse suggests nephritis. A secondary rise in temperature always sug- 
gests a complication. Cases occur with no discoverable rash and no 
fever, and these may transmit the disease in its typical form to other 
children.* The diazo-reaction is present. 

Spurious Rashes. — Unfortunately roseolas are common and often 
due to trivial causes. In differentiation one must bear in mind that 
the scarlet fever rash appears first on the chest, is seldom unassociated 
with sore throat, rapid pulse, enlarged lymphatics and decided fever 
and desquamation, following the order given in a preceding paragraph. 
Rubella should never be mistaken for it as the eruption appears first 
on the face and is macular. Indigestion. Shell fish and strawberry 
rashes lack the other essential features. Drug rashes may be traced 
to their cause and lack cardinal signs. Septic rashes are known by 
their association with other signs of sepsis, onset, etc. Syphilis. Scar- 
latina-like rash is rare in syphilis, and the other concurrent signs 
make the diagnosis. Febrile Roseola. Simple (non -epidemic). Rose- 
ola exactly simulates mild scarlatina, but its benign character and the 
history of repeated attacks may serve to distinguish it. All suspicious 
cases should be isolated, and no chances taken. 

ROTHELN. — Definition. — A trivial acute contagious exanthemal- 
ous disease of unknown causation conferring immunity and chiefly 
affecting children. 

Symptoms. — After an incubation period of from 7-21 days the 
disease begins with slight malaise, trifling fever and on the second or 
even first day the rash appears on the face, spreading rapidly over the 
body, the old areas fading as it extends. Either the measles or the 
scarlatina rash may be closely simulated but the disease protects from 
neither of these ailments and the trivial symptoms readily distinguish 
it. Neither catarrhal symptoms nor sore throat are marked but swelling 
of the post-cervical glands is common. There is practically no mortality 
or serious complication and the diazo-reaction is usually absent. 

DIPHTHERIA.— (Cynauche maligne, putrid sore throat, suffo- 
cative angina, membranous croup). 

* Any man is negligent who fails to satisfy himself each day that the 
urine, heart, throat and ears are unaffected. 



Doubtful 
rashes. 



Hard pulse. 



Location 
and asso- 
ciated 
symptoms. 



Febrile 
roseola. 



Trivial 
symptoms, 
evanescent 
rash. 



THE INFECTIOUS DISEASES — DIPHTHERIA. 



463 




Definition. — An acute highly infectious, contagious and profoundly 
toxic disease, due to the Klebs-Lcejfler bacillus, characterized by the 
development of a nasal, pharyngeal or laryngeal false membrane and 
especially affecting young children. 

Dissemination and Distribution. — The disease is well nigh uni- 
versal and is readily disseminated by contact, contiguity (cough dis- 
semination), clothing, drinking utensils, pencils, 
school books, and intermediaries such as parents, 
nurses, physicians and certain persons who un- 
doubtedly carry the germ but are themselves 
unaffected.* Such may carry the germ for 
months or years. So also food stuffs, pet cats 
and dogs, room or street dust may convey it. 

Morbid Anatomy. — Aside from the false 
membrane itself the interest centers about the 
heart, nervous system, and kidneys which are 
the chief sufferers from the diphtheria toxin. 
The most important conditions are myocarditis 
(the most frequent complication and cause of 
sudden death), laryngeal stenosis and peripheral 
neuritis. Anterior poliomyelitis or even hemor- 
rhages into the spinal cord are common and 
the cranial nerves are quite frequently affected. 
Congestion of the kidneys is almost invariable and acute nephritis not 
uncommon. The spleen is hyperaemic, the lungs not infrequently 
congested or the seat of broncho-pneumonia. 

Symptoms. — No disease is more variable in its symptoms and the 
modern physician has learned to expect diphtheria without marked freer 
or malaise and even in the absence of marked throat symptoms or the 
presence of an apparently frank and relatively innocent tonsillitis, while 
on the other hand what appears to be a true membrane upon the tonsils 
and pharynx may prove non-diphtheritic. Ordinarily there is chilliness 
and general malaise, the fever rising to 102-103 during the first day, 
and there is nearly always sore throat, and what is far more important 
as an early sign and in dubious or larval cases, enlargement of the glands 
at the angle of the jaw. If the child has been sick for some days its 
appearance and evident weakness may be out of proportion to the tem- 

*In a case recently observed the symptoms were practically nil though 
culture \\;is positive and yet a sister contracted by contiguity a virulent 
diphtheria. 



Fig. 170.— Diphtheria 
bacillus (bacillus diph- 
theria?) of Lceffler. Pleo- 
morphic, non-motile, non- 
sporogenous, non-flagel- 
late, non-liquefying, non- 
chromogenic, aerobic, 
readily cultivated and 
stained by all methods. 
F. F. Wesbrook has de- 
scribed (a) a virulent 
type with clubbed ex- 
tremities and polar gran- 
ules, (b) granular type, 
(c) barred type, (d) solid 
type. 



Ml chan- 
nels availa- 
ble. 



Infectious 
individuals 
themselves 
well. 



Organs 
chiefly 
affected. 



Diphtheria 
without 
membrane 
ami vice 
versa. 



A valuable 
sign. 



464 



MEDICAL DIAGNOSIS. 



Heart 
symptoms. 



The throat. 



The mem- 
brane. 



Nervous 
system. 



Nose and 
larynx. 



Antitoxin. 



Stenotic 
symptoms. 



"Mem- 
branous 
croup." 



perature and local signs, yet here again exceptions occur and extensive 
membrane and marked glandular involvement may co-exist with slight 
systemic disturbance. The pulse is usually rapid and not infre- 
quently irregular and irritable from the onset but its more significant 
variations appear as a rule later in the disease when it may be very 
rapid, very slow, or show decided arrhythmia. It is moreover weak and 
compressible in any established case unless there be some decided renal 
involvement. The appearance of the throat is variable and it may be 
that of a simple follicular tonsillitis, or more often shows a definite patch 
or extensive membrane spreading to the faucial pillars and perhaps to 
the uvula, naso-pJmrynx or even the larynx. It is gray or drab (mouse 
color), dirty and usually sJmggy and if removed leaves a raw bleeding 
surface which it quickly re-covers. The spread of the membrane is 
sometimes astonishingly rapid and even on the physician's first visit 
it may have reached an extreme development. The nervous symptoms 
of the early stage may be nil or consist of restlessness or delirium. In 
the later stages a state of profound nervous depression may be evident 
with or without low delirium, stupor or terminal coma. Attention 
should be paid to the nose and larynx no less than to the throat in every 
case suggesting diphtheria, as the membrane may be limitedto these regions, 
and the utmost care and caution should be exercised in allowing the child 
to assume the sitting posture and getting it out of bed during convalescence. 
So also the urine should be frequently examined and the heart auscultated 
and percussed at each visit. The wise physician will use antitoxin 
promptly in dubious cases without waiting for a laboratory report, 
though these are now furnished with remarkable promptness. Nasal 
diphtheria may at times only be detected by a rhinoscopic examination, 
laryngeal cases by the laryngoscope, but the evidence of related stenosis 
in either case, together with the symptoms of profound exhaustion which 
almost invariably accompany them will point the way In the former 
an irritating nasal discharge is common. Membranous croup has 
properly been shelved by modern methods of diagnosis and replaced by 
laryngeal diphtheria which in 99% of such cases is the proper descrip- 
tive term. The symptoms of dyspnoea and suffocation from laryngeal 
membrane do not need description but no more terrible picture is seen 
in medicine and it of course demands immediate recourse to intubation, 
and that failing, to tracheotomy. Both the nasal and laryngeal forms 
yield a higher mortality, in the latter not only because of the obstruction, 
but more because of the higher degree of toxaemia associated with 
these two varieties. 



THE INFECTIOUS DISEASES — DIPHTHERIA. 



465 



Complications. — Myocarditis is the most common one and accounts 
for many cases of sudden death. In controllable children efficiently 
treated with large doses of antitoxin it should occur less frequently 
than it now does. The uncontrollable ones practically commit suicide. 
Endocarditis is not uncommon and in any event a weak, rapid, excessively 
slow, irritable, or irregular pulse demands the utmost care and caution 
not only during the attack but long after it. 

Complicating Paralyses. — These may be extreme and severe, or 
localized and relatively slight. They most commonly affect the palate, 
occur during convalescence and almost invariably recover completely. 
The complication may be expected in between 10 and 15% of all cases 
even though treated with antitoxin. Diaphragmatic paralysis is a rare 
event but may cause death. 

Profound hemorrhages are unusual and nephritis may, but seldom does, 
prove persistent. Anazmia should receive attention as soon as the mem- 
brane has disappeared and not be postponed until late in convalescence. 

Differential Diagnosis. — The symptoms described enable any one 
to make a reasonably sure diagnosis in most cases but this is always to 
be controlled by cultural methods. The most important points are the 
membrane, its distribution, its common tendency to spread rapidly and 
involve adjoining surfaces, the decided evidence of toxozmia, glandular 
swelling and, nasal or laryngeal stenosis in certain cases. In taking a 
culture due regard must be had for the situation of the membrane 
and an attempt made to reach the larynx or nasal passage with the swab 
if the pharynx is free from exudate. Follicular Tonsillitis. The onset 
is more severe than is usual in diphtheria, the exudate is likely to be 
purely follicular (spots) and to show less tendency to rapid spread, 
is lighter, clearer and less adherent, does not as a rule extensively 
involve surrounding structures and the glandular involvement is less 
marked. // operations have been recently performed the wounded 
surface may be covered with a membrane closely resembling thai of diph- 
theria and lead to error. Vincent's Angina. — To Prof. Vincent we 
owe our knowledge of an angina which, ordinarily assuming the form 
of an ulcerative or ordinary tonsillitis or pharyngitis, may closely simu- 
late diphtheria. Two organisms are described, one a fusiform bacillus. 
the other a spirillum. 

Prognosis. — There are differences in epidemics and the surround- 
ings, previous health ami resisting power oi the individual child cut a 
considerable figure, but practically, tlic whole outcome depends upon the 
promptness with which antitoxin is administered and the adequacy 0) 



Sudden 

deaths. 



Suicides. 



All recover. 



Culture, the 
only means. 



Follicular 
tonsillitis. 



Wound 
mem- 
branes. 



4 66 



MEDICAL DIAGNOSIS. 



Smallpox 

vs. 
Great pox. 



Formerly 
inevitable. 



A medical 
hero. 



Inocula- 
tion. 



the dose. It is impossible to get accurate statistics but we know that 
without antitoxin the mortality reaches from 50-60%, while with anti- 
toxin in private practice where cases are promptly seen and children 
well nourished it may not exceed or reach 5%. 

SMALLPOX— (Variola). (A.S. pock, bag or pocket). 

Definition. — An acute infectious and highly contagious disease con- 
ferring immunity, and characterized by a definite mode of invasion and 
a -peculiar eruption. 

Historic Note. — Smallpox was so called originally in contradis- 
tinction to great pox (syphilis.) It has existed for thousands of years 
in Eastern countries, was introduced into Europe in the eighth cen- 
tury, and by the tenth had become so general throughout Europe that 
prior to the day of Jenner, few persons failed to show on the face its 
characteristic pits.* It was first brought to the American continent 
by the Spaniards in the sixteenth century, and to Massachusetts in 1633. 
The aborigines and negroes seem to be especially susceptible and 
the disease flourishes in its most virulent form on virgin soil. Once so 
general and fatal it has in our day become a comparatively rare disease 
with a low mortality. For this we have to thank that great and coura- 
geous physician, Edward Jenner, who, being convinced of the identity 
of cowpox and smallpox, in 1796 vaccinated, and six weeks later 
inoculated with smallpox virus, a boy of eight, reporting the success 
of his experiment in June, 1798. To appreciate his courage one has 
only to read the journals of that period in which he was most heartily 
denounced and abused. Prior to this time, Lady Wortley Montague 
had become convinced of the value and efficacy of inoculation as practised 
in the far East and succeeded in her efforts to introduce this procedure 
into England.f Unfortunately, the extreme care characteristic of 
Eastern nations in choosing a proper age, season and state of health 
was not observed by their English imitators, with the result that the 
good accomplished was over-balanced by the extreme mortality and 
disease incidence engendered. The Asiatic races had for centuries 
successfully practised inoculation upon a most rational basis, neverthe- 
less the disease is still a scourge in India, where effective vaccination is 
rendered extremely difficult by the attitude of the people, who believe 
smallpox to be a form of purification sent by the gods and who object 
to the use of cows for the production of vaccine. 



* An old writer has said " from smallpox and love few escape." 
t Coincidently Cotton Mather and Dr. Boylston braved adverse public 
opinion and mob violence in Boston in the same cause. 



THE INFECTIOUS DISEASES — SMALLPOX. 



467 



Etiology. — The cause of smallpox has not been established. In 
1892, Guarnieri described a parasite (cytoryctes variolar) and Council- 
man and Calkins have attempted to show the stages in the develop- 
ment of the organism but its specific nature remains unproven. 

Age and Sex. — No age and neither sex is exempt, and rarely, intra- 
uterine disease may exist if the mother be affected. 

Morbid Anatomy. — The appearance of the patient who has died 
of smallpox is sufficiently indicated by the symptomology. The lesions 
of the viscera are essentially those of profound toxaemia and high fever. 

Contagiousness. — The infectious element exists in the secretions, 
excretions, pustules and probably in exhalations from the lungs and 
the skin conveys it through the medium of the dried scales which 
are readily converted into dust. Though contagious at all stages, 
the frequent exposures without infection indicate that its early periods 
are comparatively inocuous. The contagium is difficult to destroy and 
remains active for long periods, hence the radical measures employed 
in the disinfection of rooms in infected houses. The question of con- 
duction through the air is still sub judice but has much to support it. 
It may be conveyed not only by the clothing, but by room dust, by rats, 
mice, flies or vermin, and the patient ceases to be an infective agent only 
when the last bit of desquamating skin has been removed. The severity 
of the disease bears no relation to that of the case from which it is 
derived. 

Individual Susceptibility. — This varies greatly, some being 
immune, even though unvaccinated and those sufficiently vaccinated 
being either wholly immune, or subject only to mild attacks.* 

Varieties of Smallpox. — There are six distinct forms varying 
greatly in severity, namely, varioloid, discrete, confluent, hemorrhagic, 
malignant and vcrrucose. 

Period of Incubation.— From seven to fifteen days. 

Characteristic Symptoms. — (a). Sudden onset, often with chills, 
or in children, convulsions, (b). Headache, intense and frontal; this 
corresponds to the congestion of meninges found at autopsy, (c). 
Severe backache (congestion of the membranes of the spinal cord), (d). 
Vomiting, (e). Severe pain in tJie limbs, (f). High initial temperature 

* Since the Spanish-American war, a mild form of smallpox has pre- 
vailed in (his Country and spread widely, especially in country districts, be- 
cause of its close resemblance to chickenpox, and further because the pro- 
longed immunity resulted in careless disregard of the necessity foi vac- 
cination. According to some observers the light form is gradually becom- 
ing more virulent. 



Organism 
unproven. 



Remarka- 
bly trans- 
missible. 



Early 
stages 
slight. 



Fomites 
and car- 
riers. 



Natural 
and ac- 
quired im- 
munity. 

Six forms. 



Tearing 
backache. 



4 68 



MEDICAL DIAGNOSIS. 



Peculiar 
fever. 



Important 

initial 

rashes. 



Localiza- 
tion. 



Macules, 
papules, 
and vesi- 
cles (3d- 
4th day). 



L'mbilica- 
tion (5th- 
6th day of 
rash). 

Pustulation 
6th-i2th 
day of 
rash.) 

Secondary 
fever. 

Desqua- 
mation. 



First on 
mucous 
mem- 
branes; 
next, the 
face. 



Palms 
affected. 



(103-105 F.) followed, by a marked recession and a high secondary rise 
associated with suppuration of the vesicles. (See chart, p. 57.) 

Note. — The pains are more severe than in any other definitely eruptive 
disease and in the presence of an epidemic these symptoms must be 
given great weight though they are in no sense indicative of the 
severity of a given case. 

Eruption. — Rarely the disease occurs without any true eruption or 
a tardy one, and in from 10-20% of the cases misleading initial rashes 
occur during the first two days. These assume one of six forms: — 
(1). Erythematous. (2). Urticarial (very rare). (3). Morbilliform. 
(4). Scarlatiniform (3 and 4 are extremely misleading). (5). Purpuric. 
(6). Astacoid (lobster-like). It is said that this sixth variety indicates 
a fatal issue. These eruptions may be mixed, are distinctly localized 
and limited to (a) the inner surface 0} the thighs, (b) the lateral thoracic 
areas, (c) the lower abdomen, (d) the axilla. They persist until the 
appearance of the true rash. 

The Typical Eruption. — On the third day of the disease bright red 
macules appear, readily blanched by pressure, these rapidly becom- 
ing hard elevated "shot like" papules. At the end of 24 hours these 
show vesicles and the vesicular stage reaches its full development usu- 
\ ally by the third or fourth day of the eruption. The vesicles rarely 
I exceed one-fourth of an inch in diameter, contain a milky fluid and 
are surrounded by distinct though narrow areolae. By the -fifth or 
sixth day depression of the apices of the vesicles is noticeable. This 
umbilication is usually general by the end of the first week of the 
disease (seventh or eighth day). Almost coincidentally the vesicles 
become distinctly purulent (pustulation being general from the eighth to 
the tenth day and associated with a secondary temperature rise to 
102-104 -f- / 7 .). The whole process is completed usually by the end of 
the twelfth day. By the fourteenth desquamation should commence and 
be completed at the end of three or four weeks. 

Parts Affected. — The eruption chooses by preference the portions 
exposed to light, chafing, irritation and injury, and upon them reaches 
its highest development. It usually first appears on the face and near 
the border of the hair, yet the mucuous membrane may be still earlier 
involved, the rash appearing on the buccal mucous membrane, tongue, 
soft palate, pharynx and even upon the stomach and rectum in the 
virulent cases and in none do the mucous membranes escape. The 
wrists are also affected early, and like syphilis but unlike varicella it 
involves the palms of the hands, a point of considerable importance in 



THE INFECTIOUS DISEASES — SMALLPOX. 



469 



differential diagnosis. The involvement of the larynx may cause dis- 
tressing cough and even fatal edema. 

Confluent Smallpox. — In this form all symptoms are intensified 
and in the stage of pustulation the patient presents a frightful appearance 
and a foul and characteristic odor. The face is a swollen and unrecog- 
nizable mass of fetid sores, though on the body and legs the eruption 
often remains discrete. 

Hemorrhagic Form. — (Purpura variolosa), (black smallpox), (vari- 
ola hemorrhagica). As indicated by the name, the eruption is distinctly 
hemorrhagic in type, the patient presenting a frightful appearance. In 
some cases hemorrhage occurs from any or all mucous membranes and 
it has proven fatal in from three to four days after the onset of hemor- 
rhagic symptoms though in others of milder type the hemorrhages are 
limited to the vesicles and pustules. 

Malignant Smallpox. — This is characterized by low fever, scant 
or absent eruption, profound asthenia and a fatal issue with or without 
hemorrhage, death occurring between the third and seventh days. 

Variola Verrucosa. — This varies from the other forms only in 
leaving a warty growth after desiccation and hardly deserves separate 
classification. 

Varioloid. — This is an attenuated smallpox, modified by vaccination, 
natural immunity, or a previous attack. It differs from true variola 
in the following particulars:— (a). Short duration, (b). Irregular 
or incomplete eruption which runs a rapid course, (c). The absence 
of any marked secondary temperature rise. (d). The early completion 
of desquamation. The initial symptoms are usually but not necessarily 
mild and the eruption may or may not be limited to the face and 
hands. 

Complications. — These are easily inferred from the symptoms and 
pathology of the disease, being chiefly connected with the suppuration 
and profound toxaemia. It suffices to name them: — Edema glottidis, 
necrosis of cartilages, broncho-pneumonia (sometimes initial), lobar 
pneumonia (rare), pleurisy (not uncommon), pseudo angina, diarrhoea 
(especially in children), albuminuria (true nephritis rare), orchitis, 
ovaritis, parotitis, abortion, fatal delirium, myelitis, neuritis, pysemic 
abscess, general tuberculosis, local gangrene, arthritis (suppurative or 
not), bone necrosis, otitis, iritis, keratitis, purulent conjunctivitis, phle- 
bitis, etc. 

Prognosis. Absolute figures are OUt of the question. Assuming a 
severe epidemic, from 25 to 50% of the unvaccinated will die; amongst 



Odoi 



Severe 

vs. 
Mild. 



Mild 
symptoms. 



In mn .10- 
cinated, 
great nior- 
t.Uit\ . 



47© 



MEDICAL DIAGNOSIS. 



In vacci- 
nated, neg- 
ligible. 



Disease 
type, age 
and phy- 
sique. 



Pitting. 



A boon. 



Antivacci- 
nationists. 



Revaccina- 
tion neces- 
sary. 



Immunity 
results. 



the vaccinated (varioloid) the mortality will vary according to the 
efficacy of the primary vaccination and its proper repetition (see vac- 
cination), and with the age and physical condition of the person 
attacked. The mortality in all unvaccinated cases is exceptionally great 
in infants and young children. Efficiently vaccinated persons are practi- 
cally immune and of those attacked the mortality should not exceed 
from five-tenths of one per cent, to one per cent. Of the hemorrhagic 
and malignant cases, practically all die within the first week, and the 
same is true of unvaccinated children under one year of age. Dissi- 
pation and pre-existing disease increase the virulence of the primary 
attack and its mortality, and the more profuse or confluent the facial 
eruption, the greater is the death rate. Pitting is unusual nowadays in 
the ordinary forms. 

Diagnosis. — In the presence of an epidemic, cases presenting severe 
pain in the head, back and limbs, and vomiting, must at once be under 
suspicion. Indeed lacking an epidemic they are still important and 
the greatest care should be observed when such symptoms are associated 
with the suggestive and peculiarly located initial rashes. The typical 
eruption is unmistakable and the course of the fever most significant, 
viz. : — appearing on the third day, being primarily high and dropping 
to normal, or in severe cases, to ioo° F. or 100.5 F., only to reap- 
pear with pustulation. For differential diagnosis see chickenpox and 
syphilis. 

VACCINATION. — The origin of vaccination with cowpox virus as 
the supplanter of inoculation from smallpox pustules is, as before 
stated, directly traceable to the keen observation and rare courage of 
Dr. Edward Jenner, who first proved its efficacy on May 14th, 1796. 
As a result of his brilliant work millions of lives have been saved, and 
smallpox has lost its terrors in every intelligent and civilized country. 
J Few remain who deny the efficacy of vaccination, but they are of the 
type who would insist that the sun moves around a stationary earth. 
Wherever vaccination is required and enforced by law, smallpox is a 
negligible factor. 

Extent and Duration of the Protective Influence. — It should 
be clearly understood that to be effective and efficient vaccination must 
be repeated at certain intervals. First performed in infancy, it should 
be repeated at the age of puberty, and in the presence of any especial 
liability to exposure. The experience of every physician shows almost 
absolute immunity to be the result of intelligent and repeated vaccination, 
however direct the exposure. Furthermore, the disease if contracted by 



THE INFECTIOUS DISEASES— VACCINATION. 47 1 



ma- 
tion after 
exposure. 



a vaccinated person is almost invariably the mildest possible (varioloid).* 
The false idea that one vaccination in infancy or childhood is absolutely 
'or approximately protective throughout life is altogether too widespread 
amongst the laity and much of the prejudice against vaccination, aside 
from that depending upon pure ignorance, obstinacy, or more or less 
ingenious misrepresentation, is the result of the vaccination of the The "con- 
earlier days when the virus was usually taken from the vaccinated objector." 
human being, and the operation performed with scant regard to the 
danger of septic infection. The antivaccinationists still talk of the The 
transmission of syphilis as if an innocent heifer could acquire and trans- heifer. 
mit a disease of this peculiar nature. It should be remembered that even 
though a person has been actually exposed to smallpox, vaccination will J£acc 
ordinarily either confer complete immunity, or greatly modify the disease, 
it being understood that the time elapsing between exposure and develop- 
ment shall have been sufficient to allow of some action on the part of 
the vaccine. As between cases of even doubtful vaccination and the 
unvaccinated, the ratio of mortality is as one to four. 

Preparation of Vaccine. — The material for vaccination is now in- 
variably obtained from the heifer, and the so-called humanized lymph Humanized 
should not be used, except in emergency. Various reliable firms that passe. 
prepare this substance maintain farms and conduct their inoculations 
and the recovery of the virus under the most perfect sanitary conditions. 
The source of the lymph is the vesicle produced by the inoculation of Bovine 
the udder of the cow. This is allowed to dry on sterilized ivory points 
or quills, or is treated with glycerine, and collected in sterilized glass 
tubes, so contrived as to permit their use without danger of con- 
tamination.! Method. The region of the deltoid insertion of the arm Points and 

crlvccnns- 

or the outer surface of the thigh or calf should be thoroughly cleansed ted lymph. 

with alcohol (cologne, bay rum) and washed off with boiled water. 

then lightly but rapidly scratched by a needle, knife blade, or the Vaccina- 
, ,, . ., mi tlon toch " 

point" itself, until the outer layer of the skin is removed so as to show nique. 

a punctate moist surface, free bleeding must be avoided, and the pro- 
cedure is practically painless if properly performed. The vaccine is 
placed upon and gently rubbed into the denuded area, allowed to dry 

* \)\\ Hare quotes a Case in which the father of a family in which small- 
pox had appeared, having been vaccinated in infancy refused further vacci- 
nation though exposed, at the Same time permitting it in the case of his 
wile and three unaffected children. Of these one developed a mild vario- 
loid and no others were affected at all hut the father promptly developed a 
severe' attack. 

I Bach maker Supplies directions with his tubes. 



472 



MEDICAL DIAGNOSIS. 



Shields. 



thoroughly and afterwards the affected portion is covered with one 
of the numerous forms of " shields" readily obtained at any drug store. 
Sequence of Events in Vaccination.— A reddish papule should 
make its appearance in from three to five days, promptly becoming vesic- 
ular, filled with clear lymph and later umbilicated. Its maximum devel- 
opment is reached at the end of 7 or 10 days when its contents become 
purulent in appearance. A brilliant areola surrounds the pustule, 
underlain by a tender and more or less firm or brawny area. Dur- 
ing the succeeding 3 or 4 days pain and tenderness become localized 
along the region of the lymphatics and their tributary glands may be 
slightly or decidedly swollen and inflamed, with fever and malaise.* 
The itching is intense, and scratching frequently causes secondary 
infection, hence in infants the movement of the arms must often be 
restrained. Occasionally a general eruption closely resembling chicken- 
pox may appear or there may be a distinct roseola. In from 10 days to 
two weeks these symptoms disappear, desiccation being complete as a rule 
by the end of the 15th or 16th day, the scab falling about a week later. 
A depressed pitted scar is left behind varying in size with the severity 
of the process. All sorts of variations may be met with, such as long 
periods of incubation, entire absence of constitutional symptoms, or, 
in some instances, a more prolonged and severe stage of suppuration. 
A thoroughly good vaccination usually leaves a scar which persists 
throughout the whole life of the individual. In an unvaccinated person, 
one should never rest content with a single vaccination, and in the 
presence of direct opportunity for infection or during an epidemic it is 
wise to repeat ever} 7 vaccination if the first fails. It would appear 
certain, moreover, that cases presenting unusually severe symptoms 
owe these rather to secondary infection than to the true virus, so that 
some severe "takes" are less protective than the thoroughly typical 
and milder form. 

The Previous Health. — Common sense should determine the 
propriety of vaccination in exceptionally delicate and diseased children, 
and a proper period chosen. So also as to the site of the vaccination 
the female infant or adult should, as a rule, be vaccinated on the leg' 



Duration 
of scar. 



Pseudo 
takes." 



Site of vac- 
cination. 



*The signs of inflammation and glandular abscess are often far more 
alarming than the actual result merits but, rarely, septic conditions are en- 
countered. In an experience covering nearly two decades and including 
two years of municipal relief service the author has never had or seen one 
case of death, deformity, paralysis or invalidism and is convinced that the 
few bad results reported are almost invariably due to previously existing 
syphilitic or tuberculous taint. 






THE INFECTIOUS DISEASES— CIIICKKNPOX. 



473 



the male on the arm, the resulting scar being of no moment to the 
latter. 

VARICELLA. — (Chickenpox.) A trifling infection of unknown 
causation characterized by transient fever and a vesicular eruption. 

Etiology. — Children are peculiarly susceptible between the ages 
of one and eight years, adults remarkably resistant. It prevails chiefly 
in the spring and autumn and spreads rapidly, is not inoculable, and 
one attack usually protects for life. 

Symptoms. — In from one to two weeks after exposure the symptoms 
-of mild infection appear. Malaise, chilliness, pain in the legs and 
back are associated with a mild fever, rarely exceeding ioi-io2°F. Some 
children show no fever or signs of illness save the eruption which appears 
within 24 hours in the form of minute papules changing in a few hours 
to vesicles. The face, scalp and neck are first attacked and it spreads 
to the extremities and trunk, being especially well marked in the back 
and attended by troublesome itching. The following points serve to 
distinguish varicella from smallpox or varioloid: — (a). But few or no 
vesicles in a given case umbilicate. (b). The contents are serous, not 
purulent though a few may suppurate and leave pits. (c). The uniloc- 
ular vesicles are emptied by a single puncture, (d). They rarely have 
an areola, (e). They come in successive crops lasting two or three days 
and form superficial crusts which desquamate in a week or ten days, 
(f). The vesicles therefore are seen in all stages, i.e., the eruption is 
not uniform, (g). The spots may be few in number, are scattered widely 
and do not tend to become confluent, (h). The secondary fever of suppu- 
ration is lacking, (i). Vesicles rarely appear upon the palms or soles. 

Duration. — A week to two weeks. Prognosis. — Almost invariably 
good. 

Complications. — Ordinarily lacking and seldom serious. The 
eruption occasionally appears in the mouth and hard palate, but 
rarely or never involves the conjunctivae, larynx or trachea. The 
vesicles always variable in size, in rare instances become bullae, and in 
any case the harmless vesicles may be infected by scratching. Cachectic 
children in this as in other infections may present a peculiarly virulent 
eruption. 

WHOOPING COUGH. (Pertussis). Definition. - An infectious 
disease of childhood of unknown causation, self limited and immunity 

conferring, characterized by peculiarly violent paroxysms of cough, fol- 
lowed by a "whooping" sound. The disease is highly contagious, both 
before the appearance of and a week or two after the cessation oi the 



Trivial 
symptoms. 



Vesicular 
eruption 
(2d day). 



Successive 
crops. 



Multiform. 
Isolated. 



Usually 
absent. 



Highly 
conta 
in all si 



474 



MEDICAL DIAGNOSIS. 



Peculiar 
cough. 



"Whoop" 
may be 
absent. 



Paroxysms 

easily 

excited. 



Depends 

upon 

cough. 



Many and 
grave. 



Adenoids. 



A formida- 
ble disease. 



Infant mor- 
tality high. 



characteristic paroxysms but adults enjoy comparative immunity. It 
is a disease chiefly of early spring. 

Incubation. — Two days to two weeks. Duration. — Eight to ten 
weeks. Prognosis. — Good in robust young children, bad in weak- 
lings, nurslings and the aged. 

Morbid Anatomy. — Practically none save that of a complicating 
diffuse bronchitis, broncho-pneumonia, emphysema or cardiac over- 
strain. Death by inanition, starvation and inhalation — or deglutition- 
broncho-pneumonias are rare phenomena. 

Symptoms. — A coryza or mild bronchitis is associated with a short 
barking cough, progressively nervous and explosive in character and 
tending to multiply in each paroxysm, the protracted expiratory efforts 
resulting in glottis spasm and a terminal long drawn stridulous inspi- 
ration, the "whoop." The seizures vary in severity and frequency, 
absence of the whoop may obscure diagnosis, but the cough is peculiarly 
explosive and paroxysmal. Attacks may be almost constant or occur 
but once or twice a day. Any emotion, pleasurable or otherwise, food, 
dust, over-heating or a cold draught may provoke the dreaded paroxysm. 
The child may vomit, the urine or faeces may be passed involuntarily, 
and hemorrhages may occur from the nose, ears, or under the skin or 
conjunctiva. The blood shows a leucocytosis, the lymphocytes being 
relatively increased. The urine may contain a trace of albumin and 
fever may be present or absent. 

Diagnosis. — The presence of an epidemic, a persistent bronchitis, 
and the paroxysm of short, barking, rapidly repeated coughs with or 
without the whoop is sufficient for diagnosis. 

Complications. — There are many. It is frequently associated with 
measles, with subcutaneous, interstitial and true pulmonary emphysema, 
pneumo-thorax, persistent vomiting leading to inanition, enlargement 
of the bronchial glands, general convulsions, cerebral hemorrhage, 
broncho-pneumonia and lobar pneumonia, or even pulmonary tuber- 
culosis. Adenoids greatly increase its dangers and add to the severity 
of the paroxysms. 

Comment. — The laity regards pertussis too lightly. It is a disease 
of high mortality through its pneumonic complications, often induced 
by a foolish disregard of ordinary precautions. Of children under one 
year, 25% die. Between one and two years 15%. Above these ages 
the mortality is slight, but it will be seen that the disease is formidable 
and deadly if lightly regarded. In the public services of great cities it 
stands second to pneumonia as a cause of death in infants. 



THE INFECTIOUS DISEASES— SYPHILIS. 



475 



Cierm 
unproven. 



Readily 
trans- 
mitted. 



Protean. 



Essentially 
venereal. 



Occasional 
variations 
in site. 



SYPHILIS. — {Lues venerea, pox.) Etiology. — The Spirochczta Pal- 
lida of Schaudinn and Hoffman seems to be constant in active lesions 
and syphilitic blood but is not yet fully proven as the causative agent, 
and other organisms closely resembling, if not identical with it, are 
found in diverse lesions and situations in non-syphilitic cases. 

Mode of Conveyance. — Syphilis in an active form may be, and 
usually is acquired, less often inherited. Dilute inherited syphilitic 
infection is of course well nigh universal but is symptomless. It is 
both contagious and infectious, confers almost absolute life -long immun- 
ity and furthermore is capable of affecting each and every structure 
of the human body so diversely as to make it the chief of protean diseases. 
Given an abraded skin or mucous membrane in a non-immune and 
contact with the secretions or blood of a syphilitic and infection almost 
certainly follows. Less frequently prolonged contact or retained virus 
alone may produce it on a sound mucous membrane. The disease is 
essentially venereal, sexual intercourse being the means of transmission 
and sexual organs the usual seat of primary lesions. Yet owing to the 
irregular and unusual forms of intercourse and the communicability of 
the disease through certain secondary lesions and by means of interme- 
diate substances, we find labial, lingual, tonsillar, mammillary and rectal 
infections as well as the digital sore not infrequent in physicians, dentists, 
laundresses, rag pickers, etc. It follows also that syphilis may be 
innocently acquired with or without sexual congress. Husbands infect 
innocent wives and less often a guilty wife transfers the disease of her 
lover to an unsuspecting husband. The innocent girl carrying an 
oral chancre for which the mucous patches of her fiance are responsible 
is no rare client and may infect other family members. The individual 
syphilitic is a menace to all about him during the active stages, as the 
secretions of his lesions, his blood and his lymph, arc alike virulent. For- 
tunately breast milk, saliva, and usually the semen, are not infectious 
unless contaminated through local sources. The late lesions (tertian) 
are seldom sources of infection unless relatively early or co-existent 
with late secondary lesions. High degrees of heat or cold seem to destroy 
the virulence of the secretion otherwise active even in a state of desic- 
cation. 

Modifying Influences. As to its later course no correct inferences 
can be drawn from the primary symptoms or the site of the lesion. 
though the general rule governing all injections 'which leads us to expect 
the severer manifestations in persons oj bad habits, poor physique or a 
vitality impaired by antecedent or eo existent chronic disease holds 

3 ] 



The syph- 
ilitic a 
menace. 



Tertiary 
lesions not 
often con- 
tagious. 



As in other 
ailments. 



476 



MEDICAL DIAGNOSIS. 



Acquired 
lues in 
children. 



After 
effects. 



Insurance 
experience. 



Incubation. 

Papule or 
erosion. 



Induration. 



Bubo. 



Constitu- 
tional 
symptom; 



in this one. The ravages of acquired syphilis in children are excep- 
tionally violent and widespread. 

The Three Stages. — The primary stage of syphilis comprises the 
time elapsing between the recognition of a local lesion at the seat of infection 
and the appearance of the constitutional symptoms and eruption of the 
secondary period. It is represented by the development of the chancre 
and coincident swelling of the adjacent lymph glands (syphilitic 
buboes). 

The third stage or tertiary period marked by soft nodular growths of 
peculiar structure (gummata) may be entirely lacking in efficiently treated 
cases or may appear despite the most active and prolonged specific medi- 
cation. Extending beyond these circumscribed and classified periods 
is an insidious toxcemia of indefinite or life-long duration which makes 
the individual liable to develop degenerative diseases of an apparently 
non -syphilitic nature. Such are locomotor ataxia, paretic dementia, 
arterio-sclerosis, apoplexies, aneurism and the nephritides. This fact 
has led life insurance companies to exact a long period of immunity and 
evidence of radical and efficient treatment as perquisite to acceptance 
as "first class risks," yet the actuarial report of the "combined investi- 
gation" committee shows the futility of the requirement by the enor- 
mously excessive death rate experienced. 

The Initial Lesion or Chancre and the Bullet Bubo. — After an 
incubation period of from 10 days to 6 weeks the first characteristic 
symptom is apparent in a single papule often a part of an herpetic 
eruption at the point of infection whether genital or remote which 
increases in size, becomes indurated and may remain as a dry plaque 
or show an eroded surface with scant secretion* The feel is that of a 
split pea save that in certain cases especially in the female the induration 
may be lacking. Its usual location is the vulva or the prepuce, but it 
may appear upon any portion of the genitals or in neighboring or distant 
parts and always represents the actual site of infection. The glands 
representing the lymph drainage of the affected part undergo a painless 
enlargement, known, when in the groin, as the bidlet bubo. 

The Secondary Stage. — Within from 6-8 weeks after infection 
systemic infection is manifested by general glandular swelling, mental 
depression or irritability, insomnia, malaise, pallor, pain on pressure over 
or near the sternochondral joints, neuralgia, nocturnal headache, joint 

* Multiple lesions are not uncommon in women but are relatively rare in 
menjand sometimes "satellite" indurations of later formation may be 
observed. 



THE INFECTIOUS DISEASES— SYPHILIS. 



477 



pains and exertion-dyspnoea, fever being rare or if present, trivial. As 
these subside the exanthem develops. 

Exanthemata of the Secondary Period. — Their characteristics 
must be thoroughly understood because of their great importance 
in diagnosis. These are: — (a). Their polymorphous tendency. This 
may merely represent different stages in the development of a certain 
type or show a true mixed eruption. Such polymorphism is the rule in 
syphilis, (b). Symmetry and tendency to general distribution, (c). 
The tendency to follow skin lines in arrangement. As is seen especially 
in profuse eruptions and particularly in the oblique parallel lines of 
eruption from the back downward obliquely to the front, (d). The 
absence or trivial degree of itching, (e). The tendency to oval illiptical 
or circular forms, (f). The prompt response to mercurial inunctions. 
(g). The tendency to shift their pigment to the periphery of the lesion* is 
characteristic especially in the case of disappearing or past lesions. In 
the former a central faint red may be surrounded by a lighter area, in 
its turn encircled by a deeply pigmented border. In the latter the 
whole inner area is white (syphilitic leukoplasia). 

Varieties of Syphilitic Exanthemata. — The earlier syphilitic 
eruptions show a marked tendency to predominant involvement of the 
abdomen, front of chest and anterior surface of arms. 

Roseola. — This earliest form chiefly affects the trunk and is so evan- 
escent and otherwise symptomless as, in many instances to escape 
the patient's notice. f The brownish red pea sized macules are seldom 
raised above skin level and leave no trace. 

Large Macular Syphilide — Unlike roseola this is due to actual 
round cell infiltration, is usually slightly raised and frequently, by central 
fading or border coalescence, forms the varieties known as "gyrate," "cir- 
cinate," "annular," etc. The color is livid in the lower extremities, 
copper color in the upper, and its pigmentation may persist for consider- 
able periods or give place to the white areas known as cutaneous leu- 
koplasia. 

The Papular Syphilide. — This may be pure or mixed will: the macu- 
lar or pustular form and is the commonest syphilide and the most diverse 
in size and form. It may be distinctly papular, nodular or flattened, and 
in size varies from a pin head to 2 cm. or more. Its distribution may 



Kxanthem. 



Peculiari- 
ties must be 

known. 



Early 

eruptions. 



Earliest 
form 

often over- 
looked. 



Readily 
recognized. 



I oinmon- 
cst t\ pe. 



*The coppery or ham colored eruptions though suggestive arc neither in- 
variable in nor are they peculiar to syphilis. 

f Dashing other upon the surface of the body will often bring out a 

phantom like but clearly specific roseola. 



478 



MEDICAL DIAGNOSIS. 



Distribu- 
tion. 



Lenticular. 



Lichenoid. 



Tuber- 
cular. 



Suggests 
variola. 



Hemor- 
rhagic 
types. 



Onychia 
and peri- 
onychia. 



Excoria- 
tions. 

Fissures, 
ulcers and 
warts. 



be general or in later types limited to the genitals, palms, soles or other 
areas* Resembling psoriasis in some respects it lacks the silvery 
scales and peculiar localization of that disease and seldom involves 
large areas, occurring usually in small patches. The lenticular form 
is a rash of brief (7-14 days) duration followed by desquamation and 
leaving no permanent markings. Its nodules are grouped and especi- 
ally involve the extremities and trunk. The flat glistening form involves 
especially the face and is sharply defined, flattened and centrally depressed. 
It also leaves no permanent marks. The lichenoid papules are grouped, 
not generally distributed, persistent, become crusted and leave tiny pits. 
Among the later forms are the orbicular papules which show a ring 
shaped border and central depression, and chiefly affect the genital 
region. The tubercular form, very late and persistent and closely allied 
to tertiary eruptions, is grouped, scaly or crusted, richly pigmented, and 
may terminate in ulceration which leaves permanent scars. 

The Pustular Syphilides. — These are rarely early but may co-exist 
with the papular form and are associated with marked general symptoms 
(fever, malaise, pallor, etc.). The exanthem may closely resemble acne 
or even smallpox at the outset, and may form extensive crust formation. 
Ulceration, superficial and spreading (echthyma syphilitica) or deeper, 
may occur and the crusts may so arrange themselves as to be termed 
syphilitic rupia. They ' leave peripherally pigmented smooth shiny 
loose scars. Hemorrhagic forms of syphilides occur and mean a serious 
case as in other exanthematous diseases. 

Palmar Syphilides. — Both the palms and soles may be involved 
in the late secondary papular syphilides and this eruption is of almost 
pathognomonic significance.^ If these papules form between the fingers 
or toes the result is maceration and oftentimes decided inflammation 
and if the matrix of the nail or its margin be attacked syphilitic onychia 
is produced, the nail becoming dead and being finally cast off. There 
is frequently a perionychia due to suppuration at the nail margin. 

Indurative Edema. — On and near the genitals the secondary proc- 
esses may assume a most severe type of excoriation, inflammation and 
even indurative edema and these lesions are highly contagious and proba- 
bly the most frequent source of infection. Fissures, ulcers and venereal 
papillomata are associated with this condition. 

* Any papular or pustular form may be hemorrhagic in grave or com- 
plicated cases. 

t The late Mr. Berkeley Hill used to say that he always taught his students 
that any eruption in the palm was syphilis, and the exceptions are so few 
that the dogmatic statement was justifiable. 



THE INFECTIOUS DISEASES — SYPHILIS. 



479 



The Hair. — Syphilis of the scalp commonly takes the form of 
pustules which by coalescence may produce more or less irregular or 
scattered spots of baldness, sometimes replaced by gray hair, but usually, 
under efficient treatment, promptly taking on a normal new growth. 
A less common form is the seborrhceic which leads to diffuse baldness. 

The Buccal Cavity.— This region is one of the most important in 
connection with the diagnosis of syphilis in its secondary stage. The 
earliest change in the tongue consists of prominence of the papilla with 
small spots of whitish exudate; these areas later becoming raw and 
glistening, and, at the edge, converted into ulcers. Many variations 
occur in the form and distribution of such lesions. The faucial pillars, 
tonsils and soft palate should always be inspected as well as the lips and 
cheeks where fissures and ulcers may be detected. Indeed the kidney 
shaped, gray bordered ulcer of the tonsil is one of the earliest secondary 
manifestations and may be painless and so escape the patient's notice. 

Tertiary Syphilis. — This is essentially the gummatous stage and 
should never appear in a marked form in those of good constitution who 
have received adequate treatment, though in those less fortunate it as- 
sumes the most terrible types of destructive lesions, affecting the osseous 
as well as the soft tissues and leading to frightful suffering and humiliat- 
ing deformity. Large pustules may appear in this stage (pustula major) 
with rapid necrosis and coalescence, foul discharge and severe pain, 
or the various gummatous neoplasms may develop in various parts of the 
body, internal and external. The cutaneous gumma varies in size from 
a buck shot to a mandarin orange. It is somewhat soft in consistency 
and at first spares the true skin; the tendency, however, is to disintegration 
which may or may not involve the skin according to the deep or super- 
ficial situation or the growth. In certain instances the peculiar serpig- 
enous ulceration so characteristic of the disease may appear and leave 
its characteristic sinuous, reniform or semicircular scars. The gummata 
may involve the bone, periosteum, muscles, joints or tendons, the painful 
swellings of which are common in the earlier stages and if the inflam- 
mation be severe may result in fibrous anchylosis. 

Syphilis of the stomach has already been referred to, the soft palate is 
often affected at its junction with' the bony portion, the process tending 
to a pathognomonic perforation (see page 7); or, the hard palate itself 
may be involved. Indeed space will not permit a description of the 
gummatous cJiauges, inasmuch as they may involve any region of the 
body and are dealt with in other sections. 

The Lymph Glands. .1 general glandular hyperplasia characterises 



Baldness. 



Tongue. 

" Mucous 
patches." 



Important 
regions. 



May never 
appear. 

May cause 
destructive 
lesions. 



Cutaneous. 



Serpigen- 
ous ulcera- 
tion. 



Osseous 
forms. 



Soft and 

hard palate. 



480 



MEDICAL DIAGNOSIS. 



the secondary stage and may be exaggerated in any group of glands 
which drains an ulcerating surface. The post cervical, inguinal, axillary, 
epicondylar and posterior mastoid glands are especially affected and are 
easily palpated. Occasionally a similar glandular swelling occurs in a 
tertiary period, not infrequently ending in necrosis. The tongue may be 
the seat of tertiary as well as secondary changes in the form of leuko- 
plasia or gummata, the latter of which may produce painful or perma- 
nent fissures and deforming scars, as the result of ulceration. The 
so-called syphilitic psoriasis as affecting either the tongue or buccal 
mucous membrane is recognized by the presence of whitish patches 
which are hard and horny to the touch. These are easily eroded and 
constitute an intractable and painful tertiary lesion. 

Hereditary Syphilis. — Little need be said concerning the appear- 
ances in this condition beyond that contained in the first section of the 
book. The unfortunate inheritors suffer especially from the following 
lesions: (a). Syphilitic hemorrhage of the newborn leading to death 
shortly after delivery, (b). Ulceration and hemorrhage from the navel 
usually uncontrollable and resulting in death, (c). Snuffles. The nose 
[ is blocked by syphilitic inflammation and there is usually an excoriat- 
I ing secretion and a specific periostitis which may produce saddle nose. 
| (d). Excoriations, due to maceration of papular and pustular eruptions, 
| about the nates, (e). Marked nutritive disturbances which give to the 
| child a wizened, senile appearance, the skin being dull, inelastic and 
often hanging in folds, (f). Pemphigoid lesions, which occur early in 
infancy (the first few days) and usually justify a fatal prognosis. In 
addition one finds enlargement of the liver and spleen, epiphyseal inflam- 
mation and even separation, iritis, keratitis, conjunctivitis, etc. 

Syphilis Hereditaria Tarda. — This term is applied to those forms 
of hereditary syphilis which appear about the fifth year or sometimes 
as late as the twelfth and tend to last until the age of twenty or twenty-one. 
The Hutchinsonian syndrome is: — hazy cornea or actual interstitial 
keratitis, increasing deafness and crescentically notched, prominent 
upper incisors. To these Mracek would add a flat or depressed nose, 
fine scars at the angle of the mouth, on the upper lip, or on the mucous 
membrane of the lips radiating from the nares, and prominent frontal 
bosses, together with a manifest arrest of development. 

Comment. — The student must remember that syphilis is the most 
protean of diseases and frequently assumes forms unrecognizable by any 
save therapeutic tests. Whether the patient be infant or adult, male 
or female, cleric or convict, as a possibility it always exists, for the 



Glands 
most ac- 
cessible. 



Tongue. 



Buccal 
membrane. 



Pathogno- 
monic 
signs. 



Snuffles. 



" Sore 
bottom." 



Senile phy- 
siognomy. 



Jonathan 
Hutchin- 
son's syn- 
drome. 



Therapeu- 
tic test. 



THE INFECTIOUS DISEASES— SEPSIS. 



481 



innocent suffer even as the guilty though less often, and the physical 
results of the errors of youth cannot always be obliterated. In this 
condition it may be said that when one encounters conditions peculiarly 
baffling and indeterminate in their symptomatology, syphilis and drug 
addiction should always be considered. 

ERYSIPELAS. — Definition. — An acute infectious and contagious 
disease due to the streptococcus pyogenes and characterized by a 
spreading dermatitis with marked toxaemia. Etiology. — The disease 
is particularly common and easily induced in women after delivery, 
cases of surgical operation and in elderly patients or those debilitated 
by chronic disease. Syphilitics are especially liable and may suffer 
excessively.* 

Symptoms. — After an incubation period varying from three days to 
a week and with or without slight malaise, tingling or burning of the 
affected surface, there is chilliness or an actual rigor and a high, some- 
what irregular fever (103-105 F.) associated with marked leucocytosis. 
The affected skin is dull crimson, swollen, tense, persents a slightly raised 
edge and later becomes covered with blebs. In favorable cases it 
remains but a few days, gradually fades and is followed by desquama- 
tion, the fever ending usually by crisis. Relapses are common and in 
unfavorable cases the process may shift its seat and a typhoid state may 
develop. Differential Diagnosis. — The author knows of no other 
disease that presents these symptoms. 

PYEMIA AND SEPTICAEMIA.— These are essentially surgical 
conditions and need no extended description in this volume. 

Diagnosis. — This depends upon a septic temperature or one which 
may resemble at first that of typhoid fever or malaria but is associated 
with marked leucocytosis in any resistant patient, lacks the Widal test of 
typhoid and hcemamceba of malaria and is oftentimes associated with 
scarlatina-like rashes or toxaemic jaundice. Pycemia must be traced to 
its focus and is distinctly septic from the start having a widely remit- 
tent or intermittent temperature associated with recurring chills and 
sweats. Aside from the surgical conditions these two diseases are 
likely to be confused only with typhoid fever in the former case and 
malaria in the latter or with both. Ordinarily care and a study of the 
symptoms is always sufficient to make a differential diagnosis. It is 
also necessary, however, to have in mind malignant endocarditis as a 

* In one case oi imperfectly treated syphilis the onset of erysipelas was 
attended by immediate periostitis and necrosis of the facial bones which 
produced tremendous deformity and death within a few days. 



No one 
above sus- 
picion. 



Syphilis 
and drug 
addiction. 



Once com- 
mon, now 
relatively 
rare. 

Syphilitics. 



Pathogno- 
monic 
signs. 



Differen- 
tiation. 



Typhoid 
and ma- 
laria. 



Surgical 

conditions 

sequels. 



482 



MEDICAL DIAGNOSIS. 



Tuber- 
culosis. 



A vanish- 
ing disease. 



Slightly 
infectious. 



possibility, and the heart should be examined in every case where either 
septicemic or pyaemic symptoms are present. Advanced tuberculosis 
is a septicaemia in part but offers few difficulties in its pulmonary form, 
and as an acute miliary process lacks leucocytosis. 

LEPROSY. — This, the most ancient of known diseases, is caused by 
the bacillus leprce* and still prevails throughout the world, though to a 
very limited and rapidly diminishing degree in Europe and North Amer- 
ica, and, indeed, in all countries where modern methods of control 
through segregation have been attempted. 

Mode of Conveyance. — Much difference of opinion still exists 
concerning the direct and hereditary conveyance of this disease. As 
regards the latter it is probable that leprosy, like tuberculosis, may, 
but rarely does exist at birth, and that it is in nearly all cases acquired, 
the young children of leprous parents being especially exposed to the 
bacilli which are found in nearly all excretions and secretions of affected 
cases. Most intimate contact seems indispensable to infection, inas- 
much as nurses and doctors in leprous settlements are rarely attacked. 

Development of Leprosy. — The close resemblance of leprosy to 
tuberculosis in many particulars is no less remarkable than the likeness 
of its stages to the development of syphilis. There is of course an 
initial lesion believed by many to be represented by an ulcer on the 
nasal septum. There is a prodromal stage resembing the second 
stage of syphilis in that it is associated with transient fever, headache, 
joint pains, and commonly with epistaxis, possibly due to the septal 
ulceration, and exhausting sweats may occur without fever. After several 
months or even a year or two a febrile paroxysm is accompanied by 
macular eruptions. The circumscribed erythematous patches are 
generally distributed, chiefly affecting the back of the hand, the forearm, 
the face, the malar and supraorbital regions being especially affected, 
the scalp usually spared. 

The macules may be hypercesthetic early, but later become anoesthetic, 
either centrally or wholly. They are at first transient but tend to 
become persistent and pigmented. Without further advance they may 
show a loss of pigment and then constitute the dead white, shiny 
areas of "white leprosy." A definite third stage is represented by 
three forms, the nodular or tuberadar, the anoesthetic, and the mixed. 



Suggestive 
resem- 
blance. 



Primary 
sore and 
constitu- 
tional 
symptoms. 

Macular 
eruption. 



Macular 
anaesthesia. 

" The silver 
men." 



Third 
stage. 



*The bacillus is morphologically indistinguishable from the tubercle 
bacillus and resists decolorization in much the same manner. It cannot be 
readily cultivated; however, stains much more easily and does not produce 
tuberculosis in inoculated guinea pigs. 



THE INFECTIOUS DISEASES — ANTHRAX. 



483 



Leontine 

facies. 



Necrosis 
and de- 
formity. 



Three 
diagnostic 



Nodular leprosy may lack the macular stage and the subcutaneous 
tubercles are fiat, hard and elastic to the touch, and most numerous 
about the ears and face. Their increase in size and the infiltration of the 
affected parts produce the il leontine facies ." With occasional disap- 
pearance and reappearance in individual areas, they nevertheless mul- 
tiply and ultimately involve the greater portion of the body and 
mucous membranes and break down into ulcers which cause horrible 
deformities from tissue loss and cicatricial contraction. 

Anaesthetic Leprosy. — This is characterized by an extensive painful 
neuritis due to direct invasion of the nerves by the bacilli. Extensive 
anaesthesia results, associated with bullae, spreading ulceration, and sub- 
sequent contractures. Muscular atrophy is widespread, and fingers 
and toes may be completely destroyed. 

Mixed Leprosy. — Represents merely a combination of the two forms. 
Differential Diagnosis. — Any difficulty is limited to the early cases 
of the macular or anaesthetic type. Three diagnostic criteria are 
available. (1). The easy recognition of the bacillus in the blood of a 
leprous nodule, or, in anaesthetic cases, in the fragment of a nerve, usually 
also in the nasal secretion which may be increased by the administration 
of an iodide. (2). The central anaesthesia of early macular areas. (3). 
The administration of pilocarpine to show the absence of perspiration 
in the involved areas (Baelz). 

ANTHRAX. — (Malignant pustule, charbon, wool sorter's disease). 
This world-wide scourge of cattle and sheep may be conveyed to man 
through direct contact or by the handling of 
wool and hides, the channels of entrance being 
chiefly wounds or abrasions of the skin, the 
pulmonary tract, the infected stings of insects 
and the gastro-intestinal tract. The germ is 
strikingly resistant, the spores especially so, 
infection being possible after years through 
laboratory cultures or in pastures containing the 
buried bodies of infected animals. It grows 
readily on ordinary media at temperatures be- 



Sources of 
infection. 




tween 12 and 45 C, producing in gelatine 



Fig. 171. — Anthrax hacil- 
lus (bacillus anthracis). A 

non-motile. non-ehromo- 
Kenic, sporogenous aero- 
bic bacillus, readily culti- 
vated, stained by all meth- 
ods and highly resistant. 

stab cultures the inverted pine tree figure. 
They produce spores only in culture and stain with all ordinary dyes. 
The disease is rare in the United Stales, very frequent in certain 
parts of Russia, particularly Siberia. 

Symptoms. -The disease may be external or internal, in the 



Vitality oi 



: 



4 8 4 



MEDICAL DIAGNOSIS. 



former assuming the type of "malignant pustule" or " malignant 
anthrax edema." The latter form is usually pulmonary, more rarely 
intestinal. 

Malignant Pustule. — From three days to a week after exposure 
the development of a small itching papule is followed by a rapidly 
increasing inflammation and infiltration and the formation of a hemor- 
rhagic vesicle which becomes necrotic and bears upon its infiltrated 
marginal zone similar lesions. Coincident with the rapid spread of the 
inflammation adjacent lymphangitis and glandular swelling are evident. 
The induration and edema are extreme and the necrosis may be exten- 
sive yet pain is slight or absent. Marked constitutional symptoms are 
evident in 48 hours when the germ reaches the blood but the active 
septic phenomena including the fever subside in the later stages, the 
septic typhoid state preceding death. 

Malignant Anthrax Edema. — Primary constitutional symptoms, 
excessive gangrenous edema with a predilection for the eyelids, head, 
hand and arm characterize this variety; the patient's mind may be clear 
and free from apprehension in either form. 

Internal Anthrax. — (a). Wool sorter's disease. A sudden onset 
with chill, prostration, severe pain in the back and extremities, a temper- 
ature (102-103) with chest pain, rapid breathing and in some instances 
marked bronchial symptoms, characterize this form. The pulse is 
weak, vomiting and diarrhcea may occur, violent cerebral symptoms are 
noted and death may result within 24 hours, (b). The intestinal form 
is due to ingestion of the germs and is characterized by chills, moderate 
fever, vomiting, diarrhcea, marked prostration, dyspnoea, phlegmon or 
petechiae and enlarged spleen. Hemorrhage may occur from free 
mucous surfaces, and unlike the external form, anxiety is marked and 
there may be terminal convulsions. 

Diagnosis. — The occupation of the individual is almost always 
suggestive and the history of an itching papule and its vesication and 
necrosis should lead to an immediate examination of the contained 
serum, either microscopically or by inoculation of white mice which 
are very susceptible. A progressive course with falling fever eliminates 
phlegmonous erysipelas and diffuse cellulitis and malignant edema 
shows tissue crepitation. The germ can often be recovered from the 
blood within 48 or 72 hours after the onset, but may be long delayed. 

Prognosis. — The mortality is variable but always high in the internal 
forms and those of the external type in which the face is involved; less 
so if the extremities are affected. 



External 
forms. 



Character- 
istic lesion. 



Constitu- 
tional 
symptoms. 



Curious 
predilec- 
tion. 



Pulmo- 
nary, gas- 
trointesti- 
nal and 
cerebral 
symptoms. 



Hemor- 
rhage. 



Occupa- 
tion. 



Falling 
tempera- 
ture. 



THE INFECTIOUS DISEASES — RABIES. 



485 



HYDROPHOBIA.— (Rabies, Lyssa.) A fuller knowledge and more 
radical precautions have rendered rabies a rare disease in America, 
England and Germany. It depends upon a specific virus conveyed to 
man chiefly by the dog, though most animals are susceptible in varying 
degrees, as is proven by successful inoculation and by cases observed 
in cats, skunks, wolves and even cows. The salivary secretion is the 
chief carrier, the nervous system the main focus of this unknown poison. 
The incubation period varies inversely with the age of the victim, 
is shortest when following wounds of the face and head, but depends 
also upon the size of the wound, the protection of clothing and the ani- 
mal conveying it. The infected dog stands below the wolf and cat in 
virulence. It is stated that infection follows in about 15% of dog bites 
as compared with about 40% for wolves but it would seem that the 
severity of the lesion might be chiefly accountable. The mortality 
varies from 50 to 80%, but has been greaty reduced by the Pasteur 
treatment. 

Symptoms. — The Premonitory Stage. This is characterized by irri- 
tability, insomnia and apprehension and marked mental depression, 
photophobia and hyperacusia may be present. Hoarseness and dys- 
phagia usher in the second stage. 

Period of Hyperesthesia and Spasm. — (Duration 2 or 3 days). 
The slightest stimulus, physical or mental, excites painful and violent 
reflex spasms affecting chiefly the mouth and larynx and accompanied 
by subjective dyspnoea. The mind is clear except during the con- 
vulsions and the paroxysms excited by attempts to swallow even water 
account for the use of the term "hydrophobia." Fever may be absent 
but is usually present in moderate degree. Attempts to injure others 
are rare and confined to the paroxysms. 

Terminal and Paralytic Stage. — Subsidence of the spasms, gradu- 
ally developing coma and progressive cardiac weakness terminate life. 

Lyssophobia. — (Pseudo-hydrophobia). This is merely an hysterical 
manifestation on the part of one bitten by a suspected animal, fever is 
rare and the signs of hysteria usually manifest, though naturally the 
irritability, apprehension and menial depression may exactly simulate 
the premonitory stage of the true disease. The excessive hyperesthesia, 
true spasm and other indications of actual infection can hardly be 
exactly simulated. 

Diagnosis. The greatest runny of the patient and diagnostician is 
the officious public servant or citizen who promptly destroys and disposes 
of a suspected animal, for (lie first step should be the transfer of the living 



Saliva the 
medium. 



Important 
factors. 



Extreme 

irritability 

andspasms. 



1 m aginary 
hydropho- 



Fool 
heroes. 



i 



4 86 



MEDICAL DIAGNOSIS. 



Diagnosis 

usually 

easy. 




animal or of the fresh brain and medulla to the hands of the bacter- 
iologist the purpose of the inoculation of animals and the identification 
of the Negri bodies.* Hence if possible the canine suspect should be 
kept confined and carefully watched, and if killed be transferred at 
once to competent hands. This should seldom be necessary for actual 
diagnosis as the clinical picture is clear, but it often prevents an unrea- 
soning and unfounded dread in a community 
where some halting physician diagnoses hys- 
teria as rabies and causes the persecution of a 
wholly innocent dog population. 

TETANUS.— (Lockjaw). The bacillus re- 
sponsible for the lockjaw is an anaerobic germ, 
motile, inoculable in animals and yielding an 
antitoxin which permits the production of a 
protective serum. Its peculiar toxin is fatal in 
the extraordinary dose of 0.23 milligram. As 
tetanus neonatorum the disease especially affects 
newborn children in countries or districts where 
uncleanly methods are followed in the care of 
the navel. The soil of certain regions is peculiarly infectious and the 
germ usually enters the body through a punctured or contused wound. 
The fatalities attending the use of toy pistols are well known. 

Symptoms. — After a period of incubation of about a week or ten 
days, or more rarely two weeks, a subjective sensation of constriction 
of the neck and jaws with difficult mastication is followed by a tonic 
spasm of the muscles which locks the jaw, the outdrawing of the mouth 
and raising of the eyebrows causing the risus sardonicus. By gradual 
involvement the muscles of the trunk and extremities are affected, pro- 
ducing rigid extension (orthotonos), or violent posterior flexion of the 
spine (opisthotonos), and more rarely lateral flexion (pleurosthotonos) 
or anterior flexion (emprosthotonos). The duration of the spasms is 
variable, relaxation usually incomplete; they are initiated by the slightest 
irritation and are extremely painful. The fever is usually moderate 
or perhaps absent, more rarely there is hyperpyrexia. Spasm of the 
glottis may cause dysphagia and paralysis of the facial muscles may 



Marvelous 
toxicity. 



A soil 
dweller. 



Incubation 
period. 



Locked 
jaw. 

Risus Sar- 
donicus. 



Opisthot- 
onos. 



Fig. 172.— Tetanus bacil- 
lus (Bacillus tetani). A 
long slender bacillus with 
single polar spore, flagel- 
late, motile, anaerobic, 
non-chromogenic, sporog- 
enous, liquefying, readily- 
stained by all methods but 
cultivated with difficulty. 



Fever. 



* Negri's bodies are protozoon, angular, round or oval, varying from 1 to 
2o}J- in diameter. Negri's original claims have been largely substantiated 
by other observers and the micro-organism seems to be almost or quite con- 
stant and found in no other disease. They are found most readily in the 
Cornu Ammonis. By this means a diagnosis can be made within 24 hours, 
and fortunately the bodies are quite resistant to post mortem changes (Poor). 



THE INFECTIOUS DISEASES — GLANDERS. 



487 



occur, but in children spasm may be limited to the production of the 
risus sardonicus. 

Diagnosis. — Strychnine poisoning lacks the early involvement of the 
muscles of mastication and the rigidity between spasms. (See p. 640.) 

Prognosis. — Of idiopathic cases about 50% die, traumatic cases 
80%. The head tetanus due to wounds of that part, is in its acute 
form, almost invariably fatal; if chronic, the mortality may only be 

25%- 

GLANDERS. — (Farcy). Primarily a disease of the horse, it is 
communicable to man through the agency of the bacillus mallei. It 
is essentially an infective granuloma, actual contact being the usual 
method of conveyance, and it is encountered in both acute arid chronic 
forms. 

Acute Glanders. — (Infection through the nostrils). Three or four 
days after infection there is fever and evidence of local sepsis. The 
mucous membrane of the nose becomes involved within 48 or 72 
hours, nodules forming which undergo necrosis, the ulcers yielding a 
muco-purulent discharge. Pustules form about the face and joints, the 
cervical lymphatic glands are especially enlarged, the nose is swollen 
and pneumonia is a frequent complication. The disease is fatal in 
from 8 to 10 days. 

Acute Farcy. — (Infection by the skin). The symptoms are those of 
an acute septicaemia following local phlegmon representing the site 
of inoculation, together with an acute lymphangitis characterized by 
subcutaneous nodules in the course of the lymphatics, which may 
suppurate and are called "farcy buds." The urine may show the 
germs. Death usually ensues in from 10 to 15 days. Both varieties 
of the disease show a chronic form lasting for months or even years and 
occasionally terminating in recovery. The inoculation of animals and 
cultural methods are often necessary for diagnosis. In all forms the 
occupation serves as a valuable suggestion and it is usually possible 
to find the source of infection in a diseased horse. 

ACTINOMYCOSIS.— This disease which also belongs to the infec- 
tive granulomata is caused by the streptothrix actinomyces or ray- fun- 
gus, and constitutes the "lumpy jaw" of cattle. Successful cultivation 
and animal inoculation have proven the germ, and the pus from the 
lesion shows characteristic opaque yellow granules from \ to 2 mm. in 
diameter. Infection occurs, doubtless, through the entrance oi the germs 
into the mouth or air passages of man, and the disease is divisible into 
four forms according to the seat of the primary process. 



Head 
tetanus. 



Primary 

intra-nasal 

lesion. 



Dermal 
lesion. 



" Farcy 
buds." 



Chronic 
glanders 



Character- 

j id low 
granules. 



4 88 



MEDICAL DIAGNOSIS. 



Simulates 
pulmonary 
tubercu- 
lous. 



" Sun- 
stroke " a 
misnomer. 



Physical 
condition. 



Rational 
explana- 
tion. 



Coma. 



Hyperpy- 
rexia. 

After 
effects. 



If the digestive tract be involved there is swelling of the face, usually 
unilateral but sometimes bilateral, closely simulating sarcoma or ter- 
tiary syphilis. The tongue may be affected or the disease may be found 
along the digestive tract where it is reported to have produced specific 
appendicitis, colitis and even peritonitis but the liver is rarely affected. 

Pulmonary actinomycosis is characterized by a chronic, wasting 
febrile disease with marked pulmonary symptoms simulating chronic 
bronchitis, disseminated tuberculosis, broncho-pneumonia, or .tuber- 
culosis associated with interstitial changes and cavities. In the diges- 
tive form the organism may be recovered from the stools, in the pul- 
monary form the presence of actinomycoses in the pus and the absence 
of tubercle bacilli makes the diagnosis clear. 

Cutaneous actinomycosis closely simulates tuberculosis of the skin. 
Cerebral actinomycosis yields symptoms of brain tumor or abscess. 

THE INTOXICATIONS— (Sunstroke, thermic fever, insolation, heat 
exhaustion, siriasis.) Great heat with decided humidity are the chief 
factors in both heat exhaustion and sunstroke. Mere exposure to the 
sun does not cause it, the highest degrees of heat being borne in the 
western deserts with less liability to sunstroke than would be experienced 
at a much lower temperature on the seaboard or in a marshy district. 
Furthermore, it occurs both night and day, in doors and out of doors. 
Physical exhaustion, lack of food or water, an unsound heart or kidneys, 
and the use of alcoholics are important contributive factors. 

SUNSTROKE. — Symptoms. — The assumption that inadequate 
heat dissipation is associated with excessive heat production due to 
exhaustion of inhibitor}' centres, and the fact that at autopsy an exten- 
sive pulmonary, cerebral, hepatic, and renal congestion is present suf- 
fices to explain the symptoms. These are primarily vertigo and 
oppression followed by sudden coma with or without a convulsion. 
The facies is that of apoplexy without paralysis, i.e. lividity and cyan- 
osis, stertorous breathing and pupils fixed in contraction or dilatation 
and there is an associated hyperpyrexia (105-112-1-). Death may 
occur within 12-48 hours. Relapses are not infrequent and the stroke 
j may be followed later by meningitis. The after affects endure for 
years in the shape of discomfort on exposure to unusual heat and 
humidity or actual attacks of heat exhaustion or sunstroke. This ac- 
quired vulnerability is recognized by all life insurance companies. 

Differential Diagnosis. — The extreme high temperature excludes 
everything save pontine hemorrhage which is itself excluded by the 
absence of paralysis. 



THE INTOXICATIONS. 



489 



HEAT EXHAUSTION.— This is characterized by subnormal tem- 
perature, sweating and collapse, and is wholly unlike sunstroke. 

ALCOHOLISM. — The well known effects of large potations need 
not be described, yet many mistakes arise in connection with the uncon- 
scious or stuporous stage. It should be remembered that in alcoholism 
the pupils are usually dilated, the individual can be partially roused by 
pinching the inner side of the upper arm or thigh, that the temperature 
is normal or more frequently subnormal, the breathing, deep, slow but 
rarely stertorous. The fact that the breath is alcoholic is important 
but far from conclusive evidence. 

CHRONIC ALCOHOLISM.— The symptoms of this condition may 
be patent to any layman, or entirely absent. The face of the sot requires 
no description here, but quite as great destruction may be going on in 
the tissues of one of his fellows whose habits may be wholly unsuspected, 
even, as happens in rare instances, by his family members. A certain 
spree drinker of the author's acquaintance has for years left home at 
regular intervals, gone to a hotel, quietly passed into an alcoholic stupor 
only to arise in the late forenoon of the following day, take a Turkish 
bath and proceed with the business of life. Such is the sneak drinker. 
Others drink openly and boisterously, yet others quietly, continuously 
and in a routine way without themselves suspecting the formation of 
any habit or the creation of secondary diseases. The kind of stimulant 
taken is important; pure beer and good wines are the least injurious, 
absinthe, brandy, whiskey and gin the most harmful. The poisonous 
sophisticated liquor so generally sold in low groggeries is peculiarly 
pernicious in its effects, and the drinking of strong or mixed liquor on 
an empty stomach so common in this country is an unmixed curse, 
fostered by the " treating" habit. 

Visceral Alterations. — Digestive System. Chronic gastric catarrh 
frequently associated with hepatic cirrhosis is a common sequence. 
Gastric dilatation in beer drinkers, and the coated tongue and foul 
breath of the heavy drinker of stronger liquors is well known. /;/ the 
kidneys the chief change is found in simple hypertrophy though inter- 
stitial nephritis is undoubtedly promoted by the drinking habit The 
lungs seem to be rendered more vulnerable to bronchitis and tuber- 
culous processes, the circulatory system shows a tendency to myocardial 
degeneration and arterio-sclcrosis. /;/ the nervous system both general 
and local changes may occur, the morning depression, mental irrita- 
bility, impaired concentration and quickness of perception, failure oi 
memory and a decided change in the moral character being common 



Unlike 
sunstroke. 



Acute. 



Sneak 
drinkers. 



Uncon- 
scious 

drunkards. 



Sophisti- 
cated 
liquors. 



Cirrhosis. 
gastric 

dilatation. 



Renal and 

circulatory 
lesions. 

M.i> simu- 
late " pa- 
resis." 



- — 



49° 



MEDICAL DIAGNOSIS. 



and well known manifestions. Recurrent or persistent tremor, espe- 
cially marked in the morning hours, and even transient or persistent 
delusions may occur. 

Alcoholic neuritis is described on page 606. Alcoholic epilepsy 
is a curable form occasionally encountered and the so-called "wet brain" 
and its symptoms have been described on page 610. One of the unfor- 
tunate results of the early morning malaise, impairment of digestion and 
mental depression is the fact that it largely or wholly disappears if a 
brisk stimulant is taken and thus the vicious cycle is maintained. 

DELIRIUM TREMENS .—(Mania a potu.) This condition is invar- 
iably associated with chronic alcoholism, never with a spree of whatever 
length in an habitually temperate person. In the chronic drinker it 
may result either from some excess or from sudden withdrawal and is 
frequent in such persons following an accident, surgical operation or 
some great emotional shock. Its association with acute disease and 
especially with pneumonia is well known to clinicians. 

Symptoms. — One of the first evidences is tremor associated with a 
marked depression, restlessness and insomnia, which leads to increased 
potations. Within 24 or 48 hours or even less an active voluble delirium 
appears and sooner or later the well known hallucinations known vulgarly 
as "the horrors." Friends become enemies seeking to deprive him of 
life and liberty; the commonest noises are misinterpreted; imaginary 
snakes, rats or other animals surround him, and he is in a constant and 
pitiable state of terror. Such patients need to be watched, and, usually, 
restrained, though seldom dangerous save to the furniture and them- 
selves. The tremor of the tongue and hands is extremely marked, 
there may be a fever of mild degree, insomnia is constant and the disease 
subsides by lysis in three or four days unless death occurs from exhaustion 
' and heart failure. The frequent existence of some serious injury and 
the development of pneumonia in these cases should never be forgot- 
ten. This is particularly true of those patients seen in public serv- 
ices, who have been brought in by the police. Indeed apical pneu- 
monias are not infrequently associated with a delirium closely simulat- 
ing that of alcoholism. The fact that 10% or more in such services 
die, emphasizes the importance of the ailment. Recurrence follows 
1 continued excessive drinking and usually shows an increased severity 
and higher mortality. 

MORPHINE AND COCAINE HABITS.— These topics have 
been discussed under case-taking, see page 40. 

CHRONIC LEAD POISONING.— The relation of occupation to 



" Morning 
bracers." 



Results 
from 

chronic al- 
coholism. 



Tremor, 

insomnia, 

depression. 

Delirium. 

Hallucina- 
tions. 



Restraint 
required. 



Mode of 
death. 



A common 
error. 



Recur- 
rences. 



CHRONIC LEAD POISONING. 



4 9 I 



lead poisoning has already been discussed, see page 44. Accidental 
contamination of drinking water by lead is common through faulty 
plumbing, the use of cosmetics and hair dyes and the adulteration or 
faulty preparation of foods and beverages. It is claimed that females 
are more susceptible than males, and adults more than children. 

Symptomatology. — The chief lesions represent peripheral degen- 
erative neuritis, and aside from rare cases of anterior cornua degenera- 
tion, the brain and spinal cord are spared, though marked cerebral 
symptoms are sometimes observed and a peculiar feature of lead 
paralysis is the preservation of sensation and the extraordinary fre- 
quency of musculo-spiral paralysis. The kidneys and gastro-intestinal 
tract are also frequently affected. The most characteristic symptoms 
are: — (a). The "blue line" on and within the margin of the gums The blue 
unaffected by the toothbrush and representing a black sulphide of lead 
deposited in the papillae. It may be faint, stippled and blue-black 
and when present is almost pathognomonic, (b). Colic. A violent I 
diffuse spasmodic abdominal pain unassociated with tenderness and 
relieved by pressure is a common and characteristic symptom. There 
may be associated diarrhoea and persistent dull pain between the par- 
oxysms. High tension pulse and vomiting are sometimes observed, 
(c). Paralysis. If paralysis ensues the arms are most often affected, Paralysis, 
usually bilaterally, occasionally unilaterally and the nerves of both 
arms and legs or of the whole body may be affected, but the 
tendency is to limitation to muscle groups. Hence we distinguish 
a musculo-spiral variety associated with wrist drop in which the Types- 

1 • 11 i a j / r~ < HUlSCulo- 

supinator longus is usually spared. A peroneal type (10 to 15% ! spiral and 
of cases) involving the common extensor of the toes and that of [ 
the big toe and associated with foot drop and the steppage 
gait. The brachial type is bilateral and involves the brachialis Brachial 
anticus, supinator longus, biceps and deltoid, and occasionally the 
pectoral muscles. An Aran-Duchennc type is interesting because 
of its resemblance to the first stage of progressive muscular atrophy, 
the paralysis involving the small muscles of the hand and produc- 
ing atrophy of the thenar and hypothenar regions. The laryngeal Laryngeal. 
form is rare and consists of an adductor paralysis. Various combined 
palsies may be noted and general paralysis may be either oi a gradual 
or rapid development , in rare instances simulating Landry's disease. 
// should be remembered Unit sensation is usually preserved, a certain 
amount oj early pain max be present, atrophy is marked, the reaction of 
degeneration present and the forearm tremor is commonly encountered. 
32 



Aran Di 
chenne. 



chiefly 



492 



MEDICAL DIAGNOSIS. 



Cerebral 
signs. 



An?emia 
and baso- 
philia. 



Renal and 

vascular 

signs. 



Gastric 
signs and 
malnutri- 
tion. 



Sallowness 
and puffy 
eyes. 



Poisonous 
fish and 
mussels. 



Nervous 
form. 



(d). Cerebral Symptoms. Hysterical manifestations, coma, convul- 
sions, transient delirium and temporary or permanent insanity are 
occasionally encountered, (e). Ancemia is usually present in the form 
of a secondary anaemia of varying degree and basophilic degeneration 
of the red cells is constant in, though not peculiar to lead poisoning. 
In no other disease however do they appear in such large numbers. 
Wright's staining method best shows these peculiar cells (see plate II). 
(f). Arteriosclerosis and interstitial nephritis are common sequences 
of chronic lead poisoning and the examination of the urine for lead is 
not only important but indispensable in many cases for the differentiation 
of the disease. It is especially true of those varieties which exactly* 
simulate an anterior-poliomyelitis. 

Chronic Arsenical Poisoning. — The symptoms of acute poison- 
ing are essentially the same as those of cholera morbus with excessive 
abdominal pain (see page 636). Chronic poisoning possesses a complex 
symptomatology most baffling and misleading unless the case history 
suggests poisoning by arsenic. Anorexia, nausea, intermittent diarrhoea, 
attacks of colic or of abdominal discomfort are the usual gastrointes- 
tinal phenomena. Chronic bronchitis may occur, as may weakness, 
emaciation and joint swelling. The nervous symptoms range from 
those of pronounced neurasthenia to neuralgia or actual multiple neu- 
ritis. The only symptom in any way characteristic is the yellowish 
brown pigmentation of the skin observed in advanced cases and puffi- 
ness of the eyelids. Arsenical paralysis differs from lead palsy only in 
its tendency to involve the legs more often than the arms. 

PTOMAINE POISONING AND FOOD POISONING.— It is evi- 
dent that one must distinguish between the poison inherent in the 
food itself, whether affecting all or only certain persons, and poisons 
introduced by accidental contamination in manufacturing processes, 
and finally, the poisons due to putrefactive alkaloids (ptomaines). 
Under the first class we find a large number of articles which are inher- 
ently and generally injurious, such as that caused by certain fish in 
tropical countries and the mussel poisoning, which however is due to a 
known ptomaine, mytilotoxin, which produces rapid pulse, dilated 
pupils, numbness and a cold surface. Death results from collapse in 
about 25% of the cases. 

ERGOTISM is a well known form due to the fungus, claviceps 
purpurea, which produces extensive epidemics due to the use of con- 
taminated grain, the symptoms being either tonic, cramping, spasms, 
enduring hours or days and characterized by flexion of the arms, exten- 



^ 



PTOMAINE POISONING AND FOOD POISONING. 



493 



sion of the legs. Marked mental symptoms amounting to actual insan- 
ity and epilepsy may terminate the convulsive attacks. A second form 
is characterized by gangrene of the toes, fingers or more rarely, nose 
and ears, preceded by muscular spasm of lesser degree, anaesthesia, 
paresthesia and pain. 

PELLAGRA. — This disease has been recognized for more than two 
centuries in Southern Europe and occurs also in Egypt, Algiers, and 
Mexico. Its poison is contained in decomposed or fermented maize, 
whether used as a food or in the form of a stimulant of which it is the 
basis. Both the nature of the poison and its exact mode of develop- 
ment are unknown. 

Symptoms. — The symptoms are general malaise, constant cerebro- 
spinal pain, mental irritability and insomnia which last through 
the winter, while the spring is associated with the full development in 
the form of marked dyspepsia, both gastric and intestinal, more or less 
severe diarrhoea or actual dysentery and erythematous rash affecting 
the exposed surfaces of the body and followed by desquamation. Sum- 
mer brings a remission, the following spring a relapse and finally a cach- 
exia associated with disorders of the special senses and of the mind, and 
spastic paralysis of the legs associated with atrophy and contracture, 
normal superficial reflexes and increased knee jerk. Cerebro-spinal 
pain is intense, associated with troublesome paresthesia, and anaemia 
and emaciation are profound. 

Prognosis. — The disease lasts for a decade or more and furnishes 
a considerable proportion of the cases of insanity encountered in Italy. 
As might be expected the autopsy shows chronic exudative meningitis, 
occasionally hemorrhagic sclerosis of the posterior and postero-lateral 
columns and degeneration of the peripheral nerves. 

LUPINOSIS— (Lathyrism). (Chick-pea disease). This ancient 
disease is due to the prolonged use of the common vetch or chick-pea 
as food as is common during times of famine in British India, France, 
Italy and Algiers. 

Symptoms. — With gastro-intestinal disturbance as a prodrome the 
onset of pain with weakness and tremor is followed by spastic par- 
alysis of the legs with exaggerated reflexes and normal sensation. 
Death occurs from intercurrent disease. 

MEAT POISONING.— Whether due to the ingestion of poisonous 
sausage, pork, beef or veal, milk or cheese, the symptoms are, in gen- 
eral, malaise, anorexia and nausea or certain vague pains, abdominal, 
cervical or general. In sonic instances chilliness or rigor, vertigo or 



Gangre- 
nous type. 



A strange 
disease. 



A common 
and serious 
ailment. 



494 



MEDICAL DIAGNOSIS. 




Fig. 173. — Trichomo- 
nas vaginalis. (After 
Tyson.) 




Fig. 174 .-Me- 

gastoma Enter- 
icum.(G r a s si 
and Schewia- 
koff.) 



S 



tremor precede the attack. The actual onset is characterized by acute 
gastro -intestinal disturbance resembling cholera morbus, violent abdom- 
inal pain, marked prostration, sweating, severe 
headache and thirst. Fever varies from ioo° to 
105 F., and the pulse is usually rapid. 

LACQUER POISONING.— This disease of 
lacquer workers strongly resembles the ivy 
(Rhustoxicodendrom) poisoning of 
this country, differing only in the greater severity of its 
symptoms. The base of lacquer is the balsam of the 
Rhus vernicifera. 

PARASITIC DISEASES.— RHIZOPODA.— ,4w^a 
dysenteries. Is the chief member of this group and has 
already been discussed under amoebic dysentery, see 
page 281. Other forms of amceba apparently non- 
pathogenic are occasionally encountered in the stools, 
urine, mouth and lung cavities, the mode of introduction 
being little understood. 

FLAGELLATA — The three varieties ordinarily en- 
countered are probably non-pathogenic and merit no 
extended description. The pear-shaped trichomonas 
vaginalis is from 15 to 20 micra long, and 7 to 12 micra 
wide. Its blunt end carries a nucleus and 3 or 4 flagellar 
It is a common constituent of acid vaginal secretion. 
Another pear-shaped organism, Megastoma Entericum is 
10-21 micra long, .and 5-12 micra wide. From the 
edges of a marked depression upon its anterior surface 
project three pairs of cilia, another pair springing from 
its pointed end. The cercomonas 
hominis or trichomonas intestinalis, also pear-shaped, 
measures from 10-16 micra, carries 2 or 3 flagellar, 
and sometimes a visible nucleus. The Balantidium 
coli may or may not be pathogenic. It is a small 
oval ciliated organism and carries 2 nuclei, one 
spherical, the other reniform. Its blunt end shows 
a funnel-shaped opening. It has been found on and 
within the intestinal mucosa and submucosa, as well 
as free in the stools. (50-100 micra in length.) 

TREMATOD A.— (Flukes, distomiasis). The most important of 
these organisms is the Bilharzia hcematobia or Schistosomum hcema- 



> 



Fig. 175.— Cer- 
comonas homi- 
nis (Trichomo- 
nas intesti- 
nalis). (Pri- 
bram and Da- 
vaine.) 




Fig. 176. — Balan- 
tidium coli. (After 
Malmsten and 
Leuckhart.) 



THE PARASITIC. DISEASES. 



495 




tobium which causes endemic hematuria prevalent in Egypt, North 

and South Africa, Arabia, Persia and the West Coast of India. Only 

isolated imported cases are encountered in 

Europe and America. The accompanying 

illustration shows the peculiar relation of 

the sexes. The embryos are free swimming 

and the organism reaches the intestinal tract 

directly or indirectly through contaminated 

water. Once ingested the organism is found 

chiefly in the portal veins, but ultimately in 

other portions of the body, especially the 

bladder and rectum. The eggs laid in tissues 

may also make their way to the bladder and 

intestines and escape with the urine and 

faeces. In the tissues they may cause papil- 

lomata and fibroid processes or even form 

the nucleus of a vesical calculus. 
Symptoms. — The foregoing description 

indicates the seat, diverse nature and variety 

of symptoms, which are of course chiefly 

those of haematuria, abscesses and irritation 

of the urinary tract, dysenteric stools, rarely Glissonian cirrhosis and 
a varying degree of anaemia. The diagnosis 
depends upon the finding of the characteristic 
eggs. 

The Faciola Hepatica or distomum hepaticum 
is a small fluke measuring 20-30 mm. in length, 
carries fine spines and is a rare source of 
infection in man. Its eggs measure 130-150 
micra. 

The Distomum lanceolatum or lancet fluke 
is 8-10 mm. in length, and 1.5-2.5 mm. in 
width, and carries no spines. Infection in 
man is excessively rare, the intermediate host 
being the snail. 

The Opisthorchis Felineus measures S-10 
mm. in Length, and 1.5-2 in breadth. It is a 
translucent yellowish rod parasite not uncom- 
mon in Siberia and occasionally found in Germany. 

The Opisthorckis Sinensis or distomum spathulatum is like the 



Fig. 177.— Male (a) and fe- 
male (b) of Bilharzia hsema- 
tobia. (After Looss.) 




[78. FasciolaHepa- 
(After Wood.) 



496 MEDICAL DIAGNOSIS. 



preceding variety in size and color, its egg measuring however 20-35 
by 15-21 micra. It is abundant in India, China, Japan, and is occasion- 
ally seen in America. 

The foregoing liver flukes produce a chronic disease chiefly affecting 
children, often members of one family and characterized by marked 
hepatic and gastro-intestinal symptoms, chief amongst which are 
irregular diarrhcea, becoming bloody, hepatic enlargement, slight fever, 
variable amount of pain and intermittent jaundice, anaemia, emaciation, 
and finally general anasarca. 

The Paragonimus W ester mani is a pulmonary fluke of a reddish 
brown color and oval form, measuring 8-10 by 4-6 mm., its eggs 
measuring 56 by 90 micra. It prevails widely in China, Formosa, 
Korea and Japan and is occasionally found in the United States. The 
symptoms produced are repeated attacks of haemoptysis, trivial or 
severe, and chronic cough with rusty sputum. It should be remembered 
that all of the flukes found in man are flat, leaf shaped bodies with 
ventrally placed suckers, and that all save the Bilharzia are herma- 
phrodite.* 

CESTODES— (Tapeworms). These are long, flattened and seg- 
mented worms, each carrying both male and female sexual organs and 
lacking a digestive tract. The head or scolex carries suckers and in 
some varieties encircling hooks. Unless 
the head be removed the worm may con- 
tinue its life and growth by budding. Each 
and every segment carries sexual organs 
placed along the border in the taeniae and 
in the median line in the bothriocephalus. 
The number of eggs is enormous and they 
may show a developed embrvo. „. „, c 

J r j ^jg 179.— laenia bagmata. 

Taenia Saginata or Mediocanellata is iMediocaneiiata). (After: Pri- 

bram and \\ ood.) 

the common tapeworm of this country and 

Europe, sometimes called the unarmed or beef tape-worm because 
lacking the hooklets and frequently conveyed by beef. Its head is 
larger than that of the taenia solium, measuring 2 mm. or more in 
breadth. Its form is shown by the accompanying illustrations. Its 
segments measure from 17-18 mm. by 8-10. The ova are not 
distinguished from those of taenia solium. A length of 15 to 20 or 
even 30 ft. may be attained. 

* The measurements throughout this section on the most part follow the 
descriptions given by F. C. Wood, James Tyson and Pribram. 




THE PARASITIC DISEASES. 



497 



Taenia Solium. — The taenia solium or pork tapeworm, common in 
Europe or Asia, but infrequent in this country. It is shorter than the 
taenia saginata, seldom exceeding 12 feet in 
length. The head is smaller, rounder and 
provided with double circlet or hooklets in 
addition to its suction discs, the neck is nar- 
row and threadlike. The segments measure 
1 cm. by 7 to 8 mm. The structure of the 
uterus and general form of the worm is shown 
in the accompanying illustration. In man 
and pigs the ova develop and the free armed 
embryos pass to different parts of the body 
and develop as cysticerci. 

Bothriocephalus Latus. — This cestode 
egg though largely confined to Switzerland and 
and (c) of taenia solium. (Pri- Japan and the coast of the Baltic is occa- 

bram and Wood, modified 

segments.) sionally encountered in immigrants and has 

recently been found in Minnesota 

in a number of cases as reported 

by Wesbrook. It is conveyed by 

the pike or other fish; the adult 

worm measures 25 or more feet in 

length, is unarmed and carries two 

lateral grooves upon its head. 

Amongst the other forms of cestodes 





may be mentioned the 



Fig. 181. — Bothriocephalus Latus. (a) 
head (magnified), (b) egg, (c) head, neck 
and proglottides. 

ogono- 

porus grandis or krabbea grandis found in 
man only in Japan, the dipylidium caninum 
common in the dog, very rare in man and 
also occurring in the canine and human 
flea and dog lice. The hymenolepsis nana 
or tcenia nana, a small worm but 5-45 
mm. in length, and 0.7 in breadth. This 
worm rarely found in man finds its host in 
the rat, its habitat chiefly in Italy. Its 
head carries 4 suckers and a row of from 
24-28 hooklets. The egg is oval or round 
and measures from 30 to 37 micra, the 

cmbyro carries 6 hooks. Hymenolepsis diminuta or taenia Savopuncta. 

This small worm measuring 30 60 cm. by 3.5 mm., the head 0.2 by 0.5 




Fig. 182.— 1 1 ymenolepsis nana 
(a) head (magnified), (b) egg 
(c) booklet, in) head and proglot 
tides. (After Brann, modified.) 



49 8 



MEDICAL DIAGNOSIS. 



Hydatid 
cysts. 



mm. is armed and oval. The eggs 60-70 by 70-80 micra are yellowish 
and show faint radial striation. Butterflies, beetles, mice and rats are 
its commoner hosts. 

Symptoms. — These may be those of anaemia and slight gastroin- 
testinal and nervous disturbances or an anaemia undistinguishable 
from pernicious anaemia save by finding the parasite. 

Davainea Madagascariensis. — Is a rare parasite found in British 
Guiana, India, and Africa. It is but 30 cm. in length, and has an armed 
head with 90 hooks and 4 suckers. The ova measures from 6-8 micra, 
has two spikes and a double shell. 

Taenia Echinococcus. — This interesting tapeworm inhabits the 
dog which becomes its conveyer to man. Australia and Iceland are 
the chief sources of infection, nearly half the Australian dogs being 
affected, and about J of those in Iceland. In other countries it is rare. 
The adult worm consists of about 3 or 4 members and measures about 
2.5 to 6 mm. in length. The breadth of the head is 0.3 mm. It carries 
4 suckers and is supported by a short neck. The head is armed with a 
double circle of from 28 to 50 hooks. The uterus and general form 
are well shown on page 300. 

Mode of Infection. — Direct transfer from dog to man may result 
from close contact especially in such countries as Iceland and Australia, 
where dogs are numerous and in close relation to their masters and 
family. Contamination of drinking water is also easily understood. 
If the small six-hooked embryo is released through digestion of its shell 
it passes through the intestinal mucosa to various portions of the body, 
chiefly of course the liver. Wherever it lodges small double walled 
cysts about 1 mm. develop, the hooklets disappear and the fibrous 
envelope results from the slight inflammatory reaction. These 
( primary cysts later develop secondary cysts through budding from 
the inner layer and these daughter cysts are structurally identical 
with the primary ones. Later they are released and a dozen or 
more may be found within the parent cyst. Each daughter cyst 
may itself reproduce by budding until the original cavity represents 
a long family line. Scolices develop carrying hooklets and sucking 
discs and representing the young worm and thus a multitude may 
arise from a single cyst. The fluid is primarily non-albuminous, 
limpid, and of a specific gravity from 1005-1010. The cysts may en- 
dure for many years, ordinarily undergoing a resorption and ultimate 
calcification, the hooks persisting even in obsolete cysts. Rupture 
is always possible, symptoms and danger depending upon the loca- 



THE PARASITIC DISEASES. 



499 



thrill. 



tion. Suppuration is a serious but unusual event, most common in 
the liver. 

Distribution .—About 50% of echinococcus cysts occur in the liver, 
20% in other abdominal organs some at less than 10% each and the 
pulmonary tract and nervous system. 

Symptoms. — The size and location of the cysts determine the physical 
signs and subjective symptoms and the discovery of the hooklets in the 
faeces, urine, sputum, etc., makes the diagnosis positive. Obscure 
symptoms referable to the organs most often affected are especially 
suggestive in Icelanders and Australians. The hydatid thrill is almost 1 
pathognomonic but often absent even in relatively superficial cysts. 
It may be felt as a prolonged exquisitely fine thrill echoing the stroke 
of ordinary finger pleximeter percussion, but more clearly when the 
middle one of these pleximeter fingers is finally percussed without the 
usual recoil of the percussion digit. In one case observed by the author 
the case was symptomless, though evidently of hepatic attachment 
but the thrill at once solved the problem. 

Aside from the foregoing points a minute discus- 
sion of the host of symptoms is futile as there are 
none other than those of similar growths in different 
anatomic areas. Suppuration produces the picture 
of abscess, septicaemia or pyaemia. 

Perforation may involve any adjacent structure 
and produce the symptoms peculiar to lesions of 
that organ; urticaria is said to be a peculiar and 
frequent accompaniment of perforation. Multi- 
locular elastic or fluctuating tumors always suggest 
hydatids especially when in the hepatic and renal 
regions, but as pulmonary phthisis and gangrene, 
all forms of abscess, pericardial effusion, cardiac 
dilatation, pleuritic effusion, hydronephrosis, renal 
calculus, pyelitis, a distended gall bladder and even 
hepatic syphilis and carcinoma have been con- 
founded with it it is evident that exploratory punc- 
ture is often required. Hooklets are seldom absent. 
In the central nervous system the symptoms are those 
of tumor. Finally it should be emphatically stated that in many cases 
no symptoms of importance appear, that in general the impairment 
of health and nutrition is relatively slight in the absence oi complications 

and that recovery under operation is the rule. 



11 




• 


)H 



Misleading 
symptoms. 



Fig. 183.— Ascaris 
lumbricoides. (a) fe- 
male, (n) male, (c) 
et, r £. (d) head. (Pri- 
bram and Wood.) 



5°° 



MEDICAL DIAGNOSIS. 



Largely 
gastroin- 
testinal o 
nervous. 



Not dis- 
tinctive. 



Itching. 



Nervous 
symptoms. 



Ascaris Lumbricoides. — This, the most common intestinal parasite 
requires no intermediate host and infests the upper portion of the small 
intestine. The male measures 15 to 17 cm., the female 20 to 25 cm., 
it is earthworm like in form. Being migratory they are most frequently 
recovered from the stools, but may be found in the appendix, the bile 
ducts, in vomitus" or may even enter the pharynx, larynx, trachea. 
Eustachian tube, nasal passages or lachrymal duct. Usually but from 
two to ten are present, but they may exist in quantities sufficient to 
cause intestinal obstruction. Rare cases of intestinal perforation are 
reported, but are probably instances in which the presence of the 
worm is accidental rather than causative. 

Symptoms. — A few worms may be present without symptoms. 
Pallor, restlessness, irritability, nose rubbing and picking, bad breath, 
anorexia, colicky pains, tympanites, malaise, impaired nutrition, disturbed 
sleep with teeth grinding. Complex and misleading nervous symptoms 
such as epileptiform seizures, general convulsions, tetany, vertigo, 
aphasia and even actual paralysis, localized or haemiplegic, as well as 
recurrent febrile attacks are among the symptoms attributed to this 
parasite. As a matter of fact each and all are merely suggestive and 
the diagnosis can never be made unless the worms or their eggs are 
found. They are excessively rare in infancy and most common from 
the 3rd to the 10th year. 

Oxyuris Vermicularis . — The "pin" or " thread" worm measures 
4 mm. for the male, 10 mm. for the female. These 
migratory parasites infest the folds of the lowest bowel, 
seldom being found above the caecum, though rarely 
they migrate as far as the pharynx or perforate the 
intestine and form "verminous tubercles." In the 
stools they resemble bits of white thread and are 
readily dislodged by appropriate medication. The 
prominent symptoms are genital and anal itching 
with nocturnal exacerbations and such other symp- 
toms as have been described as associated with the , 

rig. 184.— Oxyuris 

round worm, save the nervous symptoms are less vermicularis. (a) 

, ... 1 i n • • female, (b) male. 

prominent and mucous colitis and such renex irrita- 
tion symptoms, frequent urination or incontinence and balanitis, 
vaginitis and perhaps masturbation are common. Here also the worm 
or its ova are essential to diagnosis, and are easily found, often indeed 
about the external genitals or anus. The worm is conveyed from 
person to person or by infected water or food. 




^ 



THE PARASITIC DISEASES — TRICHINIASIS. 



5°* 



Prolific 
females. 




TRICHINIASIS. — In man trichiniasis depends upon the ingestion of 
infected, raw or imperfectly cooked pork. Those suffer most who eat (; nf i e rdone 
raw and underdone meat, and most of the cases encountered in this orraw r jor 
country have been Germans. It cannot be a rare condition as Williams 
reports 5% as showing infection in a series of 500 autopsies, but it is 
often unrecognized. The larvae require about 72 hours of residence 
in the intestines to become sexually mature and at the end of a week 
each female may have discharged into the lymph spaces or blood 
stream several hundred embryos. In due course these pass to the 
muscle fibres in which they create a reactive inflammation and become 
encapsulated. They may or may not so live for years. In man the 
appearance of an old cyst is that of "an opaque oat shaped body" 
(Osier) owing to late calcification. 

Symptoms.— Assuming that a sufficient number of Trichinae have 
been ingested symptoms appear in about one week and are usually 
characterized by the conjunction of acute gastro-intestinal disturbance, 
fever, usually remittent or intermittent, fol- 
lowed by muscular pain and tenderness, 
limitation of movement, edema of the face, 
extremities and surface over affected areas 
and a marked leucocytosis in which the eosin- 
ophiles often reach 50 to 70% of the total 
leucocytes. The attention should be fixed 
upon the muscle symptoms and eosinophilia, 
as the case may assume the typhoidal form, 
be complicated by albuminuria, pleurisy, 
pneumonia and dysphagia, aphonia, etc., 
etc. In other instances symptoms are of the 
scantest. The mortality is extremely varia- 
ble (2 to 30%). The diet and the grouping 
of cases may also be suggestive, but often- 
times the muscles must be directly examined if the stools, ingested food 
and other more available material fail to show the organism. Har- 
pooning the muscle is neither necessary nor proper if local anaesthesia 
and a clean incision can be employed. Man}- eases are mistaken for 
rheumatism in spite of the lack of joint Involvement and the peculiar 
muscle symptoms. 

UNCINARIASIS. (Ankylostomiasis, Egyptian chlorosis). Once re- 
garded almost exclusively as a tropical disease uncinariasis has been 



Muscle 
pain and 
tenderness. 

Puffy face. 



Eosino- 
philia. 



Fig. 185.— Trichina spiralis. 
(a) encysted in muscle, (b) 
male adult, (c) female adult, 
(personal observation) (d) 
male genital apparatus. 



Mortality. 



Direct 
diagnosis. 



proven Widespread and by no means limited to the tropics, though more 



502 



MEDICAL DIAGNOSIS. 



Eosino- 
philia. 
Color index 
low. 




Three chief 
forms. 



widely prevalent in southern latitudes. It may be found in Egypt, 
England, Europe, Switzerland, India, the Malayan Archipelago, the 
West Indies, and our Southern states furnish frequent examples. 
Stiles has described an uncinaria Americana differing slightly from the 
older form (ankylostomata duodenalis). The dimensions of both are for 
the male 7-1 1 mm., for the female 10-18 mm. (see plates). No inter- 
mediate host is necessary and the organism thrives in dirt and puddles. 
There are many reasons for believing that 
the skin may be a channel of infection. 
Adult worms may be found in any portion 
of the gastro-intestinal tract, but chiefly in 
the duodenum and rarely in the stomach or 
colon. 

Symptoms. — There may be none in cases 
showing the worm in the faeces, but ordinarily 
gastro-intestinal symptoms co-exist with 
anaemia, simple and mild, or so profound as 
to imperfectly simulate pernicious anaemia 
from which it is distinguished by normoblast 
predominance and a low color index. Stiles 
emphasizes the peculiar lack-lustre stare and 
the muddy or waxy white skin. The re- 
maining symptoms are those of profound 
anaemia with anaemic bruits, breathlessness, late edema and a peculiar 
ascites. The characteristic feature of the anaemia is the excess of 
eosinophile cells both relative and absolute, most marked in early 
cases. The proportion of these cells to the whole leucocyte count varies 
from 4 to 50%, the average being between 20 and 25%. A rise in the 
count under treatment is a good omen, a low original count or a falling 
one is a bad one. Leucocytosis is present in a majority of the cases, 
but is seldom high, a count above 12,000 or 13,000 being exceptional. 
The more advanced the disease the lower is the leucocyte count. 
The color index is as a rule low and in the tropical cases especially so, 
the same being true of the red cell count. Cell deformity is marked 
in the severer cases but normoblasts predominate. 

FILARIASIS. — This extraordinary parasite includes three chief 
species. The Filaria Bancrofti, also called Nocturna, is found in the 
peripheral blood only at night or during sleep, whereas the Filaria diurna 
is found only during the waking hours or in daylight. The Filaria 
perstans is present day and night and is said to be present in from 



Fig. 186.— Uncinaria (an- 
chylostoma) duodenale. (a) 
female, (b) male, (c) eggs, 
(d) male and female of natu- 
ral size. (Pribram, slightly 
modified.) 



THE PARASITIC DISEASES — FILARIASIS. 



503 



• -aar^ 


->r- 


©,#^ 




$Lo ( 




§3o -^ 


s o 


ifij 


1° 

7 O 


Or) s#y 


op 


O - '- ' 





f> Or-?O r 








O r, 






50-90% of West African negroes, being apparently non-pathogenic 
The Filaria demarquaii is found in the West Indies, persists day and Sub- 
night and is actively motile. The Filaria Ozzardi found in British 
Guiana and a large species, the Filaria Gigas, has been found at 
Sierra Leone. The first two forms, viz.: — nocturna and diurna are 
the only ones of clinical importance. Filaria nocturna is found in all 
tropical and many sub-tropical countries. Most of those observed 
in the northern part of this country are imported cases. In certain 
tropical regions 70% of the population of certain villages may be 
affected. 

Morphology. — Filaria Nocturna. The parent worm inhabits the 
lymph channels, the embryo the circulating 
blood, the body of the mosquito serving as 
intermediate host. The adult form is from 3 to 
4 inches in length and of the thickness of a fine 
thread. The embryo is 1-80 of an inch in 
length and about 1-3,000 of an inch broad, 
delicate and transparent and enclosed in a 
transparent sheath. If the blood of a sleeping p eC uli« 
patient be examined day or night, or that of a wak- parasite. 
ing patient by night, the microscopic findings 
are usually simple and definite. If a large drop, 
a broad smear, or, a large wet preparation be 
taken, no staining is necessary and low power 
lenses are sufficient. Both culex and anopheles 
ma) act as intermediate hosts. 
Symptoms. — No symptoms appear in the majority of cases, the Q ften 
embryos indeed being innocuous. The parent worm produces at times absent. 
either lymphatic varix or edema from lymphatic obstruction, hence 
there are produced a group of symptomatic conditions of lymphatic 
origin, (a). Hcemaiochyluria. Chylous urine always suggests filar- 
iasis. Its appearance is described on page 314 and its cause is a leakage chyluria. 
of chyle usually from the lymphatics around the kidney pelvis or bladder. 
The urine coagulates on standing and the contracted white clot ulti- 
mately floats in the milky liquid. The condition is almost symptomless, 
though rarely clots may cause retention, or loin weariness may exist, (b). 
Lymph scrotum is merely lymphatic varix of the scrotal channels ami 
painless SOfl tumors, usually in both groins also oeeur through varieose 
lymph glands. In either condition pain indicates lymphangitis, (c). 
Elephantiasis snd EUphantoid Fever These conditions occurring in 



Fig. 187.— Filaria Noc- 
turna embryo of filaria 
Bancrofti. 



5°4 



MEDICAL DIAGNOSIS. 



the tropics are no doubt generally due to the Filaria, but this is not 
true of the elephantiasis of the temperate zone. The symptoms are 
chill, high fever, heat, redness and congestion over the area of lymphatic 
involvement with inflammatory induration which persists after the 
crisis. Abscess sometimes occurs. The specific pathogenic activity 
of the Filaria diurna is not yet established. 

DRACONTIASIS. — (Guinea worm disease). The Dracunculus or 
Filaria Medinesis. The male worm is unknown, the female, cylindrical 
and smooth, measures 50 to 100 cm. by 2 to 3 mm. and carries a blunt 
hook on the head. The embryos are 500-750 micra by 25-30 and live 
in moist earth or muddy pools, finding an intermediate host in a small 
aquatic Cyclops. It is found in India, Persia, Arabia, Africa and Brazil. 
Rare cases have been reported in this country. Its preferred site is 
the subcutaneous tissue of the foot and leg, where it forms ulcers from 
which the head may protrude. Nevertheless, the stomach is the portal 
of entrance, the worm penetrating the intestine and traveling down- 
ward to the lower extremity. If hot water be poured upon the ulcer the 
embryos may in part be discharged and after spontaneous parturition 
the worm may voluntarily come forth. 

Trichocephalus Dispar. — (Whip worm). This denizen of the 
caecum and colon measures from 40 to 50 mm. and has a thread-like 
anterior, and thicker hinder portion, conical 
and pointed in the female, obtuse and often 
coiled in the male. The eggs, 0.05 mm. in 
length, carry a bud-like projection. The only 
pathogenic symptom associated with it is 
anaemia with enteritis, and this is rare. 

Dicotophyme Gigas or Eustrongylus 
Gigas. — This foot long worm, usually seen 
only in animals, is occasionally found in the 
renal region of man. 

Strongyloides Intestinalis. — This small 
worm measures 2 mm. by 0.06 mm. It is 
frequent in Southern China and has been found in Manila, Germany, 
Italy and America. If present in great numbers they cause enteritis 
and anaemia. 

Psorospermiasis. — Psorospermes gregarenidae or psorazoa are oc- 
casionally found in man in connection with obscure febrile ailments. 
In the cases reported the lesions resemble the granulomata but are 
found to contain coccidia. 




Fig. 188. — Strongyloides 
intestinalis. (a) female, (b) 
rhabditiform larva, (c) fili- 
form larva. (After Braun.) 



TRYPANOSOME FEVER AND THE SLEEPING SICKNESS. 



505 



Sleeping 

sickness. 



Course. 



TRYPANOSOME FEVER AND THE SLEEPING SICKNESS. 

— The former is an irregular fever characterized by swelling of the Fever 
spleen and lymph glands, weakness and emaciation. The latter 
is a peculiarly latent and fatal disease native to West Africa, char- 
acterized by early apathy, mumbling, hesitant speech, tremor and 
difficult locomotion. The latent period may last five or more years, 
the increasing drowsiness becomes a deep and continuous sleep 
or coma and the patient dies ordinarily of septic meningitis. The 
disease is fatal, occasionally attacks Europeans and usually lasts 
from three months to a year, dating from the commencement of 
active symptoms. The chain of proof is not complete, but it is 
certain that these organisms are uniformly present in this disease. 

The form of the organism is shown in the Parasite 
accompanying plate. It is small, actively 
motile, non-pigmented and transparent, 
measures 10-20 micra and carries a curious 
flagellum on one side of its body. It is 
extra -corpuscular and possesses an oval 
nucleus and a centrosome nearly opposite 
the attachment of the flagellum. It appar- 
ently multiplies by fission. The carrier of 
infection is a species of Tsetse fly. 

PYROPLASMOSIS HOMINIS.— Wilson 
and Chowning believe the Pyroplasma hominis 
to be the cause of the curious and fatal disease 
prevalent only in small districts of western 
Montana and particularly in a small area 
from 4-10 miles wide and 50 miles long in 
the western side of the Bitter-root river. It 
prevails only from the middle of March to the middle of July and 
seems to affect only those persons who have been bitten by ticks. 
Dr. Chowning states that these were found in every case but might 
easily be overlooked because at times only present in the hair about 
the genitals. The organism is both extra and intra corpuscular, the 
bodies arc small, hyaline, resemble the malarial fever hyaline forms. 
but at no stage carry pigment. No ameboid movement has been ob- 
served during the first stage of its development, but it is actively ame- 
boid during the second stage. It is readily found in the capillary blood 
of congested areas and the maximum corpuscular infection occurs in the 
spleen, liver, lungs and kidneys. The later investigations of Chowning 




Tsetse fly. 



Fig, [89.— Try p anoso m a 
hominis. (Dutton and Lav- 
eran.) 



Limited 
range. 



Ticks. 



Resembles 
hsemameba 
malaria?. 

Not pig- 
mented. 



506 



MEDICAL DIAGNOSIS. 



Peculiar 
rash. 



Albumin- 
uria. 




•Sarcoptes scabiei 
female. (Braun. 



and Anderson seem to clearly substantiate the claims first made, which 
were seriously questioned by Stiles and others. 

Symptoms. — After an incubation period of from 3-10 days, head- 
ache, nausea, muscular soreness and a chill or chilliness and nose bleed 
are followed by a rapidly rising fever and unduly rapid pulse and respira- 
tion. The rash appears on the third day, first on the forehead and 
extremities, later on the chest, abdomen and back. It is macular, bright 
red and becomes petechial in severe cases. 
It is profuse everywhere but on the abdo- 
men and desquamation may follow. In 
fatal cases rapid anaemia appears with sus- 
tained high temperature and a rapid weak 
I pulse Albuminuria is constant. 

Differential Diagnosis. — No confusion 
can arise if the salient points are recalled. 
The history of exposure, of tick bites, of 
discovery of the tick itself, its sporadic nature, the distribution, char- 
acter and time of appearance of the rash are sufficiently distinctive. 

Prognosis. — In favorable cases termination by lysis is initiated by 
the 1 2th day. The mortality varies from 70-90% and pernicious 
cases of rapidly fatal course are seen. 

Sarcoptes Scabiei or Acarus Scabiei. — The female is the active 
agent, the male usually absent. The habitat is a burrow in the epider- 
mis, usually of the axilla, front of the abdomen 
and more commonly the finger and toe webs 
and the lateral opposed surfaces of the digits. 
Characteristic scratch marks and erosions direct 
attention to the burrows, which appear as short 
dark lines leading to a shining spot. The female, 
which may be seen with the naked eye, may be 
removed by passing a needle along the black 
Fig. 191. — Pedicuius li ne of egg deposit to the spot which indicates 

capitis and egg. °° r x 

her presence. 

Pedicuius Capitis. — Produces irritation chiefly about the posterior 
margin of the scalp and the eggs or nits indicate by their position in 
the hair the duration of the process. 

Pedicuius Corporis. — Should be sought in the seams of the clothing, 
and the bites are dark, centered, hemorrhagic spots with a pale areola. 
Scratch marks are of course common, chiefly over the upper back and 
shoulders. Every hospital interne in a public service gets to know them. 




PARASITIC DISEASES — ACUTE RHEUMATISM. 



507 




Pedic- 



Pediculus Pubis. — This should be sought in and about the hair 
of the genital region, but is occasionally found in the axillae and the 
eyebrows. 

The macula cerulece (tache bleuatre) are subcutaneous bluish 
spots from 5-10 mm. in diameter, upon the abdomen and thigh, and are 
due to the irritation of body lice. 

Vagabond's disease is a deep pigmentation resembling that of 
Addison's disease, but due to the constant irritation 
and scratching produced by the continuous presence 
of body lice. 

Cimex lectularius (bed bug) and pulex irritans 
(flea) need no extended description. 

The sand flea or jigger (Pulex penetrans) is 
especially frequent in the West Indies and South 
America. It usually produces pustules or vesicles in the skin of the 
feet under which it grows. 

ACUTE RHEUMATISM.— This is the most important of the 
group of acute infections of the joints and possesses a sufficiently 
definite syndrome and marked tendency to specific complications to 
justify its consideration as a separate disease, though up to the pres- 
ent time no one of the numerous organisms associated with it has 
been proven causative. 

Etiology. — The disease is especially common in cold, damp, change- 
able climates, is most common in spring and fall, frequently asso- 
ciated with occupations involving exposure to wet and cold, particularly 
if combined with impure air, exhaustion, improper dietary or bad 
habits. It is said to have followed nervous shock and severe physical 
injury and to be especially common in neurasthenia and anaemia. 
Its frequent association with chorea is notable and it is the most com- 
mon source of and hence frequently associated with acute and chronic 
valvular disease of the heart. At times it seems to be epidemic though 
there are usually related peculiarities of the atmospheric sort. Its 
strong resemblance to sepsis is noticeable. 

Symptoms. — The onset is usually abrupt and is preceded by 
tonsillitis in about I of the cases. Chilliness or perhaps a rigor 
is succeeded by a rapid rise in temperature, associated with 
painful and swollen joints, perhaps showing the outline of the 
distended synovial membrane, the involvement being usually bilat- 



Germ 
unknown. 



Climate 
and season. 



Relation to 
shock and 

injury. 



Onset. 



:^> imnctri- 

era! or symmetrical in its advance, and the larger joints, especially 1 arger 
the ankle and knee, being usually first affected. 



Occasionally there is ggg^ 



33 



5 o8 



MEDICAL DIAGNOSIS. 



Sweats and 

odor. 

Anaemia. 



Cardiac 
lesions. 



How indi- 
cated. 



Termina- 
tion. 



Tendency 
to recur- 
rence. 



Gout, sep- 
tic arthritis 
and tuber- 
culosis. 



Acute 

atrophic 

arthritis. 



Monar- 
ticular. 



Suppura- 
tive. 



universal joint involvement constituting one of the most atrociously 
painful of all diseases. The patient is usually rigidly quiet and appre- 
hensive, suffering from the lightest touch or jar. The migratory 
tendency of the disease is marked; it is accompanied by acid sweats of a 
peculiar and characteristic odor and anaemia is invariable and rapidly 
produced. Hyperpyrexia is an occasional and unfavorable symptom 
and endocarditis, pericarditis and less often myocarditis are the com- 
moner complications. In these cases the heart should be examined 
carefully at every visit and any irregularity in the pulse, precordial 
pain or oppression, or sudden accession of temperature without the 
involvement of new joints, should lead to an especially careful examina- 
tion. Pneumonia and pleurisy must also be considered as occasional 
complications. The disease usually terminates by lysis and under 
modern treatment seldom lasts for more than two or three weeks though 
with the older treatment the saying that a cure for rheumatism was 
"six weeks" 1 accurately expressed both the inadequacy of the earlier 
methods and the average self limitation of the disease. It is pecu- 
liarly recurrent in tendency, especially if the anaemia and general 
malnutrition accompanying it do not receive attention. 

Differential Diagnosis. — This is seldom difficult if one remembers 
the tendency to the involvement of the larger joints, the usual bilateral 
and symmetrical invasion of joint surfaces, the accompanying acid 
sweats and the absence of septic foci. As will be seen gout tends to 
involve the smaller joints, the ordinary septic arthritis has usually a defin- 
ite focus, is secondary to an acute infectious fever, is more frequently 
monarticular and shows a tendency to suppuration. Tuberculosis is 
usually a chronic process of a well defined type and the one disease 
which cannot be differentiated positively in all cases is the acute atrophic 
arthritis which may be suspected if in any case an acute multiple arthritis 
of the rheumatic type primarily involves the smaller joints or proves 
unduly persistent and resists the well known drugs which are practically 
specific in the treatment of rheumatism. 

Other Forms of Infectious Arthritis. — In scarlatina, influenza, 
syphilis and gonorrhoea arthritis may occur, all varieties being distin- 
guished by the rarity of osseous involvement or subsequent anchylosis. 
Aside from rheumatism so called, the tendency is to monarticular 
involvement or in the purely septic polyarticular form, to the rapid 
appearance of suppuration, this being especially true of the relatively 
common gonorrhceal form which is of a chronic and persistent type. 
Those acute forms associated with the exanthemata and acute infectious 



SUBACUTE RHEUMATISM — GOUT. 



509 



diseases are especially common during, convalesence and may or may 
not suppurate, their true nature being suggested by their association. 
In typhoid there is a special tendency to a similar involvement of the 
spine. 

Tuberculous arthritis cannot be fully considered. It is marked by 
a slowly progressive, low grade inflammation with the lack of outward 
signs of inflammation giving it in the knee joint the name of " white 
swelling," though heat, pain and tenderness may be present. The 
X-Ray shows involvement of the bone, there is a tendency to the forma- 
tion of sinuses from pus accumulation, muscular atrophy is marked and 
spasm and deformities common. 

In hip joint disease there is limitation of movement, shortening, 
muscular spasm and a tendency to the formation of abscesses opening 
in the upper thigh or posteriorly in the region of the great trochanter 
or below the gluteus maximus. 

SUBACUTE RHEUMATISM.— All grades of rheumatic involve- 
ment may be encountered, with or without a history of succeeding acute 
attacks. All the symptoms are mild and frequently the chief mani- 
festations are in the sheaths of the tendons. Such cases are peculiarly 
obstinate, septic in their manifestation, yet lack suppuration, are 
especially prone to recur and often unusually resistant to anti-rheumatic 
remedies. 

GOUT. — (Arthrosia podagra). Etiology. — One of the older writers 
has said that gout is the daughter of limb relaxing Bacchus and Venus, 
another has pronounced it a sort of patent of nobility or at least a 
proof of gentle descent but this is far from being true as numerous 
cases of "poor man's gout" attest. Of the actual pathology we know 
next to nothing, it having once constituted a famous battle ground 
but never with decisive results. We know that a sedentary occupation, 
high living, the male sex, the middle age period, hereditary influence 
(with many alternatives in inheritance), lead poisoning, depressing 
emotions, overwork, traumatism, passion and other similar conditions 
are directly or indirectly related to its appearance in the individual. 

Symptoms of Acute Gout.- -The onset is sudden, usually at or 
after midnight and the great toe is the usual seat of the intense pain, fol- 
lowed by a red or purple, tense, shiny, edematous ami exquisitely 
tender swelling. Other joints may be involved primarily or secondarily 
the preference being almost invariably for the smaller. The urine 
is scanty ami high colored, sharply acid, ami contains an excess 
fo urates. The attack subsides (luring the latter part oi the day 



Typhoid 

spine. 



White 
swelling. 



Resists 
treatment. 



Poor 

man's 
gout." 



Mulilen 
onset. 



intense 
pain. 



Rapid 
swelling. 



'■*! 



Si© 



MEDICAL DIAGNOSIS. 



Course. 



A conven- 
ient term. 



Yet a real 
disease. 



Multiform 
nature. 



Affects 
women 
chiefly. 



Differs 
from gout. 



Three 
types. 



Haygarth's 
nodosities. 



only to come on again the succeeding night or at irregular intervals 
with even greater intensity, lasting oftentimes for 8-14 days unless 
the treatment is radical and effective. In the so called retrocedent 
gout the storm centre may be transferred from the toe to the stomach, 
heart, intestines, brain, or even as in a case known to the author, to the 
nose. 

Irregular Gout. — A large volume would be required to discuss the 
manifestations of this bete noir of the physician and victim. In Great 
Britain it is as shifting and misleading a condition as is malaria in our 
Southern states and as convenient a term to cloak uncertainty as was 
the old "blasted and planet " of the early times. It is certainly true, how- 
ever, that gout may affect any portion of the body in its irregular form 
and thus we find gastro -intestinal, cardiac, renal, nervous, respiratory 
and cutaneous conditions unquestionably related to gout as a primary 
cause. Amongst the ailments thus classed may be named recurrent 
abdominal colics, moderate or severe dyspeptic attacks, gravel, irritable 
bladder, gouty kidneys, non-specific urethritis, intractable eczema, 
urticaria, herpes and pruritus, pharyngitis, laryngitis, bronchitis, asthma, 
iritis and conjunctivitis, arterio-sclerosis, phlebitis, tachycardia, a 
form of diabetes, and more or less profound neurasthenia and melan- 
cholia as well as persistent and severe neuritis, migraine and neuralgia. 
Such conditions may occur independently of acute attacks or apparently 
substitute them and unfortunately are almost as likely to appear in the 
steady-going descendant as in the high living ancestor. 

ARTHRITIS DEFORMANS.— This chronic and obscure disease of 
the joints chiefly affects women, and in them is frequently associated with 
the menopause. Heredity seems to play a part, but not in connection 
with a specific joint disease such as gout or rheumatism. The disease 
is distinctly suggestive of a nervous origin, though chronic infection 
cannot as yet be excluded. It is most common between the ages of 
30 and 50, but not rare in younger persons and differs from gout in the 
absence of arthritic deposits of sodium urate and from chronic rheuma- 
tism in its marked atrophic changes in the cartilages and bones or 
hypertrophy or over-growth. The three recognized types depend upon 
both pathologic and symptomatic differences and we recognize a pre- 
dominance of changes in (a) the periarticular and synovial structures, 
(b) predominating atrophy of bone and cartilage, (c) hypertrophy. 
Osseous proliferations occurring at the joint margins are known as 
osteophytes, or on the knuckles Haygarth's nodosities. Any joint and 
I even the whole spine may become anchylosed. Marked deformity 



ARTHRITIS DEFORMANS. 



511 



and muscular atrophy and contractures are often associated with 
neuritis and trophic changes. The lateral nodules frequently seen on 
the distal phalanges are known as Heberden's nodes. They are seldom 
or never associated with cases involving the larger joints. Single joints 
may be involved, the spinal column, shoulders, hip and knee being the 
common sites. This form is most common in men and at advanced 
ages. The spine may be involved alone (spondylitis deformans, "poker 
back " ) associated with ascending degeneration of the cord, and pain, 
muscular atrophy and anaesthesia due to involvement of the nerve 
roots. If the hip and shoulder joints are also involved (spondylose 
rhizomelique) the nervous symptoms are moderate or absent and the 
whole or only a part of the spine may be involved in certain instances. 

General Progressive Arthritis Deformans. — The acute form 
exactly simulates subacute rheumatism and differentiation is at first 
impossible. The absence of a complicating endocarditis and the per- 
sistence of the inflammation in the joints first affected, together 
with the lack of reaction or response to anti-rheumatic medication 
are points of some value, strengthened by the later development of 
crepitation. Mental depression and emaciation are marked and the 
attacks frequently bear a relation to lactation and child-bearing. The 
chronic form usually succeeds one or more acute attacks and there 
is pain on movement, inflammatory swelling and a variable amount 
of effusion. The tendency is to gradual progression and symmetrical 
involvement, the hands, knees and feet being usually the earliest points 
of attack. Pain may be moderate or extreme and of the neuritic type. 
Crepitation appears, there is marked deformity as shown in figure 4, 
and finally a firm anchylosis due to periarticular infiltration and adhesion. 
The muscular atrophy, usually that of disuse, is nevertheless marked 
and may be so rapid as to suggest a central cause, which presumption is 
strengthened by the glossy or pigmented skin, onychia and paresthesia. 
The anaemia may be marked and the disease may render the patient 
absolutely helpless. 

The ordinary form of chronic rheumatism associated with a history 
of previous rheumatic attacks and lacking as a rule any extreme 
deformity or anchylosis is distinctly affected by weather changes and 
usually of relatively slight importance. In gouty arthritis there are 
deposits of sodium urate in the soft parts which lie just beneath the 
skiu and often perforate it, differing from the nodules oi hypertrophic 
arthritis in their mobility. The apparent deformity is often very 
marked, the actual destruction relatively slight. 



I [eberden's 

nodes. 



Spondylitis 
deformans. 



Spondy- 
lose 

rhizome- 
lique. 

Acute form 
like rheu- 
matism. 



Exhaustion 
and malnu- 
trition. 



Pain 

variable. 
Crepitation 
and anchy- 
losis. 



Trophic 
symptoms 



Chronic 
rheuma- 
tism. 



Chronic 
gout. 



5i2 



MEDICAL DIAGNOSIS. 



Neurone 
theory. 



Ganglion 
cells. 

Axis cylin- 
der. 



End 

brushes. 



Dendrites. 



THE NERVOUS SYSTEM AND ITS DISEASES. 

STRUCTURE. — Though incomplete, the prevailing theory concerning 
the structure and junctional activity of the nervous system has the merits 
of simplicity and ready adaptation to known symptomatology. As now 
conceived the nervous system is an aggregation of like units, each con- 
sisting of an excitable ganglion cell and cellulifugally (from the cell) con- 
ducting axis cylinder process of variable length {axone, neurit), which 
running naked or becoming ensheathed as a medullated nerve fiber, gives 
off lateral branches (collaterals) which, like its terminal, split ultimately 
into fine fibrillae known as end brushes or arborizations. The cell also 
has cellulipetally (to the cell) conducting protoplasmic processes known 
as dendrites. With relation to the cell these represent respectively the 
transmission and reception of outgoing and incoming impulses. Although 
the terminal axone arborizations of one neurone are intimately related 
to the dendrites of another it is probable that there is no actual connec- 
tion, but rather mere contact or contiguity. The function of the basic 
plasma is unknown but in the cell body are compact coils of fibrillae 
which are regarded as the true conducting elements and certain baso- 
philic granule groups known as Nissl's tigroid substance, which are so 
modified or diminished under conditions of cell fatigue or disease as to 
suggest a trophic function. 

Mode of Action. — If one assume an afferent (sensory) impulse as 
originating in any of the peripheral special sense organs (sensory den- 
drites) and considers the nature of the conducting mechanism he can 
readily appreciate the facility of transmission from one set of neurones 
to another until a reflex or voluntary centre is reached and the equal 
readiness with which its efferent (motor) fibre carries the message. 
This marvelous telegraphy is the basis of all acts, reflex, voluntary 
or automatic, and involves a maze of complicated pathways and sub- 
stations which relate to the orderly association and interaction of sen- 
sation, movement and intellection necessary to human life and normal 
activity. Regional distribution and function are both conserved by the 
grouping of cells and fibres to form sensory and motor tracts, reflex path- 
ways, trophic cells and primary governing centres. 

Conduction in Motor and Sensory Areas. — Motor impulses origi- 
nating in the pyramidal cells of the cortex pass through their axones 
to a terminal arborization in the anterior horn of the spinal cord or to 
a cranial nerve nucleus where they are received by the dendrites of the 
related neurones and through their axones conveyed to the periphery. 
The sensory impulse requires in addition to these central and peripheral 



Fibrillae. 

Chromo- 
philic 

granules. 



Conduction 
and trans- 
mission. 



Regional 
grouping. 



Motor 

impulses. 



Sensory 
impulses. 



THE NERVOUS SYSTEM AND ITS DISEASES. 



513 



neurones certain "parenthetic" neurones hence the impulse from the Parenthetic 
skin passes through the dendrites of the peripheral neurone to the spinal 
ganglion and through its axone to the cells of the cord or to the medulla 
oblongata, and from these cells, acting as parenthetic neurones, to the 



Supraclavicular 
Circumflex 

_Musculo-spiral 



Wrisberg 



Internal cutaneous 




Musculocutaneous 



Uln 



Radial portion 
Musculo-spiral 



Median 



Fig, 193 — Distribution of tbe sensory nerves of the skin of the arm, posterior aspect 

(G. R. Butler.) 



cortical or central sensory neurones. Stimuli conveyed from the centre Centrifugal 

to the periphery are called centrifugal, those carried from periphery to Centripetal 

centre centripetal, hence in general, "centrifugal" corresponds to motor im i ,ulscs - 
and centripetal to sensory impulses. 

Reflexes.- -A re/lex consists in the transmission of an impulse along Defined. 
Q sensory neurone to the reflex centre, and thence along the motor axone 



5i4 



MEDICAL DIAGNOSIS. 



to the muscle* It requires, therefore, an unbroken chain from the peri- 
phery to the centre and back to the periphery, and excessive activity 
Inhibition, is prevented by a cortical governing (inhibition centre). A reflex may 
Co-ordinate be localized and co-ordinate, in that the primary stimulus produces 
Inco-ordi- movement in a single muscle or in a limited group of muscles, or inco- 
ordinate or spasmodic, and either general or confined to certain muscle 
groups. Such are seen in general convulsions from various causes or 



Automatic. 
Cortex. 



Corona 
radiata. 




Fig. 194.— Direct sensory tract. 
Course of fibres and general ar- 
rangement of neurones. (After 
Van Gehuchten.) 



a reflex spasm associated with certain diseases, and yet another form 
of reflex may be both co-ordinate and purposeful. Reflex centres exist 
in the spinal cord, pons varolii and medulla, the former being largely 
related to muscular action, the latter to the vital but unconscious and 
automatic vital functions, i.e. cardiac, respiratory, etc. 

The Motor Tracts. — The direct motor tract arises in the cortical cells 
constituting the motor areas (see fig. 203), and its neuraxones pass through 
the corona radiata and are gathered into a narrow band occupying most 
of the posterior segment of the internal capsule ; thence they pass 

* It is primarily a centripetal sensory impulse conveyed to the reflex 
centre and there converted into a centrifugal or motor stimulus. 



^ 



THE NERVOUS SYSTEM AND ITS DISEASES. 



515 



through the crura cerebri to the pons varolii and medulla, giving off Internal 
in the latter collaterals which, with the exception oj the sixth nerve, cross pons and 
the median line to the nuclei oj the motor cranial nerves oj the opposite 




Fig. 195.— Diagrammatic reoresentation of the reflex arc. Normal 
on left, interrupted on right. It will be noted that the arc proper ex- 
tends from the percussion hammer (sensory stimulus* through the 
peripheral sensory nerve, through the ganglion of posterior root, 
through the posterior to the anterior horn where the sensory impulse 
is translated into a motor response which in turn is modified by the 
inhibitory cortical fibres. It is evident that a lesion interrupting the 
arc at either C, D, G, u.or F, will abolish the reflex, and produce flaccid 
paralysis if the nerves themselves or the cells of the anterior horn 
are seriously involved. Spastic paralysis, if the lesion be at E or \ 
with consequent exaggeration of reflexes through loss of cerebral 

control (lateral sclerosis cortical lesions*. Lesions at C and D cause 
loss of knee jerk and associated with a lesion at B represent the usual 
seat.of locomotor ataxia, (After Gowers, Butler, Herter.el alj 



side; the main bundle in passing through the medulla sends nine- 
tenths of its fibres across the median line at its lower portion to form p 

the motor decussation and the anterior pyramids, thus the original bun- 



S'6 



MEDICAL DIAGNOSIS. 



die is divided into uncrossed and crossed columns. The crossed 



Crossed 
tract. 



Direct 
tract. 



Motor 
nerves. 



fibres enter the lateral column of the spinal cord to form the crossed 
Pyramidal tract which descending, diminishes in size as it yields 
fibres at different levels (spinal segments) to form the spinal motor 
nerves, in each case ending in a terminal arborization about an anterior 



Supraclavicular 

Circumflex 

Intercosto-humeral 
Musculo-spiral 

Wrisberg 



Musculocutaneous 



Median 




Internal cutaneous 



Fig. 196.— Distribution of the sensory nerves of the skin of the arm, anterior aspect. 

(G. R. Butler.) 



horn cell which transmits the impulse through its own neuraxones 
(spinal nerves). The uncrossed tract forms the column of Turck (direct 
pyramidal tract) and its fibres cross in the anterior commissure at the 
different levels, to participate in the formation of the spinal motor 
nerves through an arborization around the anterior horn cells, exactly 
as in the case of the crossed pyramidal tract fibres. 



THE NERVOUS SYSTEM AND ITS DISEASES. 



517 



1 



The indirect motor tracts follow primarily much the same course but 
after giving off terminal arborizations to the pons-nuclei cross the 
median line in the middle cerebellar peduncle, thence they pass to the 
cerebellar cortex, and thence after arborization to the lateral funda- 
mental column and anterior horns. They are related to co-ordination 
and higher reflex and automatic movements. 



Small sciatic 



Internal cutaneous 
ranch of anterior crural) 



Internal saphenous 




External cutaneous (from 2d 
and 3d lumbar nerve) 



External popliteal 



External saphenous 



Vie. 197* — Distribution of the sensory nerves of the skin of the leg, posterior aspect. 
(('.. R. Butler.) 



Direct Sensory Tract. — From the skin the impulse passes along the 

peripheral nerve and to its cell in the posterior spinal ganglion, thence Pain.touch, 



to cells in the posterior horns which receive the stimulus and for th( 
most part transmit it by their neuraxones across the coal through the 
anterior commissure to the opposite anterolateral ascending tract, and 

through the medulla and pons to the optic thalamus where another 
cell receives and by its neuraxone transmits it to the cortex. 



tempera- 



5*8 



MEDICAL DIAGNOSIS. 



Visceral 
sensation 
and co-or- 
dination. 



The indirect sensory tract conveys stimuli from muscles, joints 
and the viscera through the posterior root ganglia and thence along the 
sensory roots to the cord where a part enters directly, and ascends in the 
posterior column of the cord of the same side as far as the nuclei of the 
columns of Burdach and Goll (nucleus cuneatus and nucleus gracilis) in 
the medulla from which centres the neuraxones (internal arcuate fibres) 
cross in the sensory decussation. Some go thence to the cerebellar 



Long saphenous 



Anterior tib 




Internal plantar 



External plantar 
Fig. 



External plantar 
[Br. post, tibial) 




Internal plantar 
(Br. post, tibial) 



Internal saphenous 



Fig. 199.* 



*Figs. 



198, 199.— Distribution of sensory nerves of the skin of the foot. 
(G. R. Butler.) 



cortex, whence they are transmitted by cells of that area through the 
superior cerebellar peduncles to the optic thalamus and red nuclei, and 
thence by yet another neuraxone to the central convolutions. Other 
impulses pass from the sensory root to the cells of Clark's column 
and pass up the direct cerebellar tract to the cerebellum, thence to the 
optic thalamus, red nuclei and cerebral cortex. 



|H^ 



THE NERVOUS SYSTEM AND ITS DISEASES. 



519 



Functions of the Sensory Tract. — The direct sensory tracts rep- 
resent chiefly pain, touch and temperature sense, the indirect sensory 
and motor tracts are intimately connected with co-ordinate movement, 
voluntary or involuntary and, of course with visceral sensation. These 
wonderful tracts govern the automatic and psycho-reflex acts of the 
human organism. 



Anterior 
tibial 




Internal plantar 



Fig. 200.* 



External saph 




Long saphenous 



Musculocutaneous 

( P>r. ext. popliteal) 



External plantai f7VP^> j£B i^'^SB Posterior tibial 

Anterior tibial 

Internal plantar 

\ : \ix. 201.* 

Figs. 198, tog, 200, 201.— Distribution of the sensory nerves of the foot. 
(G. K. Butler.) 



Functions of the Tracts of the Spinal Cord. The functions of 
the various tracts of the cord are, SO far as known as follows: The 
direct pyramidal tract is purely motor ami ils blurs cross at the level o\ .. 
tin' nerve emergence, The crossed pyramidal tract is the chiei motor tracts. 



^" 



520 



MEDICAL DIAGNOSIS. 



area of the cord representing the fibres which cross in the lower portion 
of the medulla. The peripheral nerves of both tracts are dependent upon 




CEREBELLUM 



Fig. 202.— The indirect (involuntary) 
motor tract. (After Van Gehuchten.) 




Fig. 203. — The direct (volun- 
tary) motor tract. (After Van 
Gehuchten.) 




CEREBELLUM 



N. COL. OOLL 
& BURDACH 



Fig. 204.— Indirect sensory tract. 
(After Van Gehuchten.) 



Direct the trophic influence of the anterior horn cells. The direct cerebellar 

tract represents chiefly visceral sensation and is concerned with 



THE NERVOUS SYSTEM AND ITS DISEASES. 



521 



equilibrium. The antero -lateral ascending tract (Gower's tract) is 
concerned with sensations of pain, temperature and touch, conveyed 
from the opposite side through the anterior commissure. GoWs tract 
conducts sensation from the joints, tendons and muscles of the same 
side, while in the cord, its -fibres crossing in the medulla, and it is therefore 
associated with ataxia, deficient orientation and muscle sense in general, 
under conditions of disease. BurdacWs tract conveys tactile sensations 
from the opposite side, contains many associating fibres and is crossed 
by afferent sensory fibres conveying reflex, painful, articular or muscular 



Gower'a 

tract. 



toll's tract. 



I'urdach's 
tract. 



dorsointermediate 
FISSURE. 



POSITION OF 
DORSAL ROOTS 



DORSOLATERAL. 
^•^ FISSURE 




toors 

Fig. 205.— Diagrammatic transverse section of spinal cord. (After Gerrish.) 

stimuli, hence if diseased there may be anaesthesia, ataxia, more or less 
pain and interrupted (lost) reflexes. The fundamental columns are 
related to association of different cord levels with each other and with 
the brain stem and cortex and contain both sensory and motor fibres. 
The cells of the anterior horns are trophic in function, constitute the 
nutrient cells of the lower motor neurones, and if diseased produce 
atrophy, \\A">., and paralysis, (flaccid paralysis) and loss oi the deep 
reflexes. 'The anterior horns are essentially motor, the posterior sensorv. 
The cells at the posterior angle oi the posterior commissure are probably boras! 



Funda- 
mental 
columns. 



Anterior 
horn cells. 



Anterior 



522 



MEDICAL DIAGNOSIS. 



Automatic 
centres. 



automatic centres, others in the immediate neighborhood may be 
trophic, sensory and vasomotor. 

Significance of Tract Involvement in Disease. — In locomotor 
ataxia and Friedreich's ataxia the posterior columns are chiefly involved, 
in combined sclerosis, both these and the lateral pyramidal tracts; in lateral 
sclerosis the crossed pyramidal tract is chiefly affected; in amyotrophic 
lateral sclerosis both the anterior horns and the crossed pyramidal 
tract, while in anterior poliomyelitis and progressive muscular atrophy 
the anterior horns are chiefly involved. 

Terms in Common Use. — Neurosis. — A morbid nervous state* 
Psychosis. — Morbid mental state. Functional Disease. — One which 
lacks demonstrable anatomic changes. Tremor, Spasm, Convulsions. — 
See page 30. Paralysis. — Loss of motor power. Paresis. — Impaired 
motor power. Monoplegia. — Paralysis of one limb. Hemiplegia. — 
Paralysis of one-half the body. Paraplegia. — Usually used to indicate 
bilateral paralysis of the lower portion of the body. Diplegia. — Double 
hemiplegia. Anesthesia. — Loss of tactile sense. Analgesia. — Loss 
of pain sense. Thermo -anesthesia. — Loss of temperature sense. 
Paresthesia. — Perverted sensations. Allochiria. — Sensory stimulation 
of one side referred to opposite side. Transferred or Referred Pain. — 
Irritation referred to a distant region, usually as pain, i.e., headache 
from uterine disease, knee pain in hip joint disease, etc. Delayed 
Sensation. — Time elapsing between sensory stimulus and its perception 
exceeds 1-10 of a second. Hyperesthesia. — Excessive sensibility. 
Hyperalgesia. — Excessive sensibility to pain. Ataxia. — Loss of volun- 
tary co-ordinate movements. Motor Ataxia. — Loss of co-ordination in 
limb movements. Static Ataxia. — Loss of equilibration. Cerebellar 
Ataxia. — Loss of equilibration with a peculiar drunken gait unassoci- 
ated with true motor ataxia. 

Etiologic Factors. — In a book of this character but a slight attempt 
need be made to cover the anatomy and physiology of the nervous 
system. On the other hand a discussion of the etiology and general 
laws of pathologic change and the symptoms produced by lesions affect- 
ing different centres or conduction paths must be taken up in direct 
relation to general symptomatology. 

Causes may be both direct or indirect, primary or secondary, and 
though the greater number of nervous diseases proper are distinctly 
related to structural alterations of the nervous system, the clinician 

* Neuroses may be motor or sensory, trophic or secretory, vasomotor or 
thermic, or, a combination of these forms. 



^ 



THE NERVOUS SYSTEM AND ITS DISEASES. 



523 



must always hold in mind the fact that remote disease may find its 
ultimate and perhaps chief and terminal expression in the brain, cord 
or peripheral nerve. For example, arteriosclerosis is directly respon- 
sible for most cases of cerebral hemorrhage and thrombosis, as is left- 
sided valvulitis for embolus. A peripheral neuritis may be traced to 
lead or alcohol poisoning, and in such cases, reasoning from effect to 
specific cause, one reaches a definite and potent therapeusis. We 
may consider therefore without separating primary from secondary 
lesions the following etiologic factors. 

(a). Toxcemias. Arsenic, lead, alcohol and carbon bisulphide serve 
as the type of one form; diphtheria, erysipelas, syphilis and typhoid 
of another; nephritis, diabetes and chronic auto -intoxication, severe 
ancemias and the cachexias yet another. In most instances such poisons 
produce changes in the peripheral nerves or the spinal cord, i.e. poly- 
neuritis, acute poliomyelitis, Landry's paralysis, locomotor ataxia, 
etc., the peripheral nerves being most often affected, (b). Secondary 
(metastatic) tuberculous, malignant or septic foci. (c). Affections of 
the heart and blood vessels, i.e. valvular lesions, arterio-sclerosis, degen- 
erative diseases of the heart muscles, etc. (d). Tumors. Under this 
we include gummata, sarcoma, carcinomata, tuberculous growths, cyster- 
cus cysts, etc. (e). Traumatism and its sequences including scar 
formation, (f). Meningeal inflammation, acute or chronic, suppura- 
tive or non-suppurative. (g). Caries, gumma, osteomyelitis, (h). 
Developmental defects and diseases of a distinctly hereditary type. (i). 
Certain unexplained nervous disorders denominated functional, such as 
epilepsy and chorea, (j). Certain changes of a purely senile sort, 
often premature in occurrence, and in general, degenerative and 
atrophic in type. (k). Hereditary and acquired predisposition, habits 
and environment, hold a prominent place. 

Degeneration. — Injury to the parent cell causes degeneration of its 
processes, and division of these leads to their death peripherally, but may 
not entirely destroy the function of the cell. It is interesting to note that 
secondary degeneration is limited to the neurone involved and that a 
lesser amount of atrophy may occur in a fibre not directly or exclusively 
connected with the affected cell. 

There are three chief forms of degeneration.- (0. Primary. (2). 
Secondary or Wallcrian. (3), Toxic. The first OCCUTS In the cachex- 
ias, locomotor ataxia and in senile processes. The second is character- 
ized by a degeneration chiefly affecting the peripheral segment and is a 

relatively rapid process, being complete within from a 4 weeks. As 

34 



Remote 

ailments 
as causes. 



The coll 
ami its 
process. 



Throe 
t> pes. 



5 2 4 



MEDICAL DIAGNOSIS. 



a rule the degeneration follows the direction of normal impulse con- 
duction, though in association or commissural fibres it is only partial 
and as the trophic centre of the sensory nerve is the spinal ganglion, if 
the injury or section be between the ganglion and the cord the peripheral 



SMALL CELL OP 
CEREBRAL CORTEX 



PYRAMIDAL CELL 

OF CEREBRAL 

CORTEX 



'•CERE BELLA* 
CORTEX. 




Fig. 206.— Showing course of sensory and motor fibres in the cord and the formation 
of a spinal nerve. (After Keiller, Gerrish and Dana. Slightly modified.) 



nerves do not suffer. The cells of the anterior horns are trophic for 
motor nerves and injury to them as to the peripheral nerve itself means 
outwardly progressing degeneration. The third, toxic degeneration, 
is segmental but follows the laws of Wallerian degeneration. Regen- 
eration. \Nerve cells cannot be reproduced if destroyed, but nerve fibres 



THE NERVOUS SYSTEM AND ITS DISEASES. 



525 



can regenerate though only as to the peripheral fibres, and this process, 
moreover, demands that the trophic centre be sound. 

Classification. — Whatever be the cause of organic disease of the 
nervous system, we distinguish those of general or irregular distribu- 
tion from those which chiefly or perhaps exclusively affect a definite 
tract or neuronic chain ("system disease"). In "focal" disease a certain 
portion of the brain or spinal cord may be involved together with all 
contained structures. If two or more definite conduction paths are in- 
volved one speaks of a "combined system" disease. The distinction 
cannot be exact but is convenient and conforms to known disease 
types. Anterior poliomyelitis, primarily a system disease, may be 
followed by a diffuse secondary sclerosis. In the grosser lesions 
such as those of hemorrhage, thrombosis and abscess, one finds a 
tendency to more or less rapid necrosis of tissue resulting in cyst 
formation, which may show gradual occlusion by contraction and scar 
formation. 

Sequence of Degenerative Changes. — These may be thus summa- 
rized*: — Spinal Cord Lesions. — Ascending degeneration of sensory path- 
ways, descending degeneration of motor tracts. Region of the Mesenceph- 
alon. — Degeneration of the optic tracts and red nucleus, atrophy of the 
brachia, corpus dentatum of the cerebellum, pontine ganglia, etc., and 
both ascending and descending degeneration of the fillet. Cerebellar 
Lesions. — Atrophy of the opposite red nucleus and the brachia; degen- 
eration of the median cerebellar peduncle, restiform body, lower olive, 
etc. Cortical Lesions. — Atrophy of such related structures as the red 
nucleus, fillet, opposite brachium, and the subthalamic region with 
degeneration of the optic thalamus, all directly related projection fibres 
and partial degeneration of those of association. In young children 
Wallerian degeneration results in arrested growth of the parts involved 
as is well illustrated by those adults who have had infantile spinal 
palsy. 

General Relation of Pathologic Changes to Symptomatology. 
— The following summary will suffice to show the direct and indirect 
results of (a) irritation, or (b) destruction of the motor and sensory cells 
and pathways. In the former instance we find morbid activity, in the 
latter loss of function. 

Sensory Centres and Pathways.-- Irritation. (aV Increased re- 
sponse to peripheral stimuli, i.e. hyperesthesia 01 actual pain (hyper- 
algesia, violent neuralgic pains), (b). Subjective sensations such as 

* According to I akob. 



A sharp 
contrast. 



Exc< ssh v- 



"■ 



526 



MEDICAL DIAGNOSIS. 



Absent 
response. 



Flaccid 
paralysis. 



Site of 
lesion. 



Lost re- 
flexes and 
atrophy. 
R. D. 



Prognosis. 



Spastic 
type. 

No R. D. c 

atrophy. 

Reflexes 

increased. 

Cortex 

irritation. 



Hemipara- 
plegia. 



tinnitus aurium, hallucinations, both visual and aural, and various 
paresthesias such as numbness, tingling, formication, etc. Destruction. 
Loss of sensory response to peripheral stimuli wholly cr partly as to 
all or only certain, special sensations (i.e. anaesthesia, thermo-anaes- 
thesia, analgesia, etc.), partial or complete ataxia. 

Girdle Sensation. — In locomotor ataxia, chronic myelitis and cer- 
tain cases of tumor or injury to the spinal cord or its meninges, a 
subjective sensation of constriction of the trunk may be manifest quite 
similar to that experienced after violent or prolonged fits of coughing, 
vomiting or sneezing. 

Motor Lesions. — (A). Peripheral or lower motor neurone (i.e. anterior 
horn cells, or cranial nuclei, to periphery). Paralysis is -flaccid, usually 
bilateral* (if unilateral on same side as lesion), and must be due to a 
lesion involving (a) the cells of the anterior cornua, (b) the cranial nuclei, 
or, (c) the peripheral nerves, cranial or spinal as the case may be. Fibril- 
lary twitching may be present but there is no contracture or rigidity, 
and by interrupting both the reflex arc and the trophic stimulus it 
involves a loss of the reflexes and the supervention of marked muscular 
atrophy and the electric reaction of degeneration. Not only does the 
presence of reaction of degeneration conclusively prove such a paralysis 
to be one of the peripheral neurone, but its entire absence after several 
days means early recovery. In general, the prognosis is good in inverse 
proportion to the degree of R. D. impairment. 

(B). Central Motor Neurone (i.e. cortical centres to cranial nuclei 
or anterior horn cell but not including them). On the side opposite 
an intracranial lesion there is spastic paralysis (rigidity) with secondary 
contractures, whereas marked true atrophy (aside from that of disuse) 
is lacking, R. D. absent and tendon reflexes increased by removal of 
cerebral inhibition. Irritative lesions affecting motor areas of 
the cortex may cause tonic, clonic or epileptiform spasms, athetoid, 
choreic or wholly irregular movements and muscular twitching. 

Unilateral Spinal Cord Lesions. — (Brown-Sequard paralysis). 
Loss of power is complete on the side of the lesion with anaesthesia on 
the opposite side save for a zone corresponding to the level of the lesion 
and on the same side. Muscle sense is impaired on the paralyzed side, 
retained on the opposite {anesthetic) side, and the type of paralysis is 
spastic save at the level of the lesion where the destruction of the anterior 

* Cord lesions are usually bilateral; cortical lesions crossed monoplegic, 
lesions of the region below the cortex and above the motor decussation in 
medulla, crossed hemiplegic. 



THE REFLEXES. 



527 







Fig. 207. 

1. Knee jerk elicitation. 

Method employed hy author. 

2. Simple method. 

3. A common method. 

4. Ordinary re-enforcement method. 

5. Met hod of obtaining Achilles jerk. 

6. Method of eliciting ankle clonus. 

7. Method of obtaining triceps jerk. 

8. Method of obtaining jaw jerk. 



horn cells may produce a -flaccid 
paralysis in the limited area repre- 
sented by their trophic influence.* 

Complete Transverse Spinal 
Cord Lesions. — Symptoms. — If the 
transverse lesion be complete there is 
complete flaccid paralysis and anaes- 
thesia below the lesion with lost deep 
reflexes, atrophy, and R. D. Any 
spastic paralysis indicates an incom- 
plete lesion. 

THE REFLEXES.! 

Cilio-spinal Reflex. — Stimulation 
of the cervical sympathetic by pinch- 
ing the skin of the neck dilates the 
pupil and its absence indicates a 
lesion of that nerve. 

Conjunctival Reflex. — Complete 
anaesthesia, deep stupor, or coma usu- 
ally abolishes the well known spasm of 
the orbicularis palpebrarum following 
conjunctival irritation.** 

Palate and Pharynx Reflex. — 
The latter is absent in most hysterias. 

Jaw Jerk. — Percuss the chin firmly 
by the mediate method while the 
mouth is moderately open. (A con- 
traction of the muscles of mastication.) 
Inconstant in health, marked if reflex 
excitability is increased. 

Supinator Jerk. — Tap supinator 
tendon just above styloid insertion. 



Flaccidity 
and anaes- 
thesia. 



Usually absent in health ($th cervical segment). 

*The relatively prompt crossing of the sensory paths other than those of 
muscle sense explains the anaesthesia of the non-paralyzed side and the in- 
terruption of the sensory root fibres at the level of the lesion accounts for 
the zone of anaesthesia upon that side, above which is a band of hyper- 
esthesia. 

| In general the presence of normal superficial reflexes is much more im- 
portant than their absence. +* Hysteric anaesthesia also. 



528 



MEDICAL DIAGNOSIS. 



May pre- 
cede loss of 
knee jerk. 






Triceps Jerk.— Support the arm at the elbow carrying it outward at a 
right angle to the body, let the forearm hang vertically downward and 
tap strongly the triceps tendon just above the olecranon ($th, 6lh, and 
jth cervical segments). It is absent or slight in health. 

Biceps Jerk. — Flex elbow at right angles, strike forearm near lower 
end of radius. Biceps contracting occurs only in disease (5^ cervical 
segment). 

Achilles Jerk. — Put the tendon Achilles on the stretch by extend- 
ing the leg and dorsiflexing the foot, or have the patient kneel on a 
chair with the foot unsupported; tap it sharply and in health a con- 
traction of the calf muscles follows. Its early disappearance in loco- 
motor ataxia is an important diagnostic sign (5^ lumbar and 1st 
sacral segment). 

Scapular Reflex. — Contraction of scapular muscles on stroking 
interscapular region (5th, 6th, jtli and 8th cervical and 1st dorsal 
segments). 

The Patellar Reflex* — (Knee jerk). This is best obtained by 
having the patient cross one knee over the other or better by passing 
his own arm over the opposite knee and under the knee of the member 
to be tested, so that the leg hangs free and relaxed across the wrist. 
Then the patient is told to close the eyes, join his own hands and pull 
when the word is given (re -enforcement), coincidently the tendon just 
below the patellar margin is sharply tapped with the side of the hand, 
the edge of a book or a percussion hammer. j" The forward jerk of 
the leg and foot or visible contraction of the muscle varies greatly 
in health and may be markedly increased in neurasthenia, hys- 
teria, tetanus, strychnine poisoning, rheumatoid arthritis or after 
sexual excesses and drinking bouts, and is pathologically increased 
■ in any disease which cuts off the cerebral inhibition fibres. Such 
are cortical hemiplegias and sclerosis of the lateral columns (lateral 
or amyotrophic). For clinical purposes one may assume that it is 
invariably present in health and its absence indicates a lesion inter- 
rupting the reflex arc, viz., a lesion involving the sensor} 7 or motor fibres 
(neuritis) , the posterior roots or columns, the anterior cells or even the 
motorial end plates. Hence it is lost in locomotor ataxia, anterior polio- 



Re-enforce- 
ment. 



Increased 



Lost knee 
jerk. 



* Tendon Reflexes. (Deep reflexes.) It will be noted that all of the 
tendon reflexes require that the tendon involved be slightly on the stretch, 
fcf Usually the jerk can be obtained without re-enforcement, but it usually 
saves time to carry out the entire procedure. In bed-ridden patients the 
same procedure can be carried out by utilizing one's own arm and the 
flexed opposite knee as points of support. 



THE REFLEXES. 



5 2 9 



Trueclonus 
prolonged. 

Pseudo- 
clonus, 
transient, 
irregular 
and volun- 
tary. 



myelitis, transverse myelitis of the 2nd and yrd lumbar segments (seat o* 
reflex), Landry's paralysis, Friedreich's ataxia and sometimes in chorea, 
diabetes and severe toxaemias such as diphtheria. Cases of pathologic 
exaggeration yield the "jerk'* on tapping the quadriceps tendon above 
the patella. In such cases especially "ankle clonus" should be sought.* 

Ankle Clonus. — The knee is very slightly -flexed, the heel rests in 
the palm 0} the examiner's left hand, his right grasps, extends and suddenly 
dorsiflexes the fool upon the leg. An initial series of clonic involuntary 
contractions of the muscles of the calf repeated under sustained pressure 
of the flexing hand constitutes clonus. True clonus has the same 
significance as exaggerated knee jerks in its relation to organic disease, 
being most common in lateral and disseminated sclerosis. If contrac- 
tions appear before the degree of foot flexion exceeds a right angle and 
are evidently voluntary, irregular and fleeting,, one is dealing with 
spurious clonus, usually hysterical. {2nd and 3^ lumbar segments.) 
Tonic contraction of the anterior tibial group may occur. 

Wrist Jerk. — Let the hand drop at the wrist (which is sup- 
ported), strike the extensor tendons of the dorsum just proximal to the 
wrist joint. (Usually absent or slight in health.) 

Epigastric. — Retraction of epigastrium following downward stroking 
of chest in nipple line. A continuation of this line of stroking from the 
costal margin downwards produces contraction of the abdominal 
muscles. It is of little importance or clinical value. (4th, $th, 6th 
and jth dorsal segments.) 

Abdominal Reflex. — Elicited by stroking outer side of abdomen at 
various levels (8th, gth, 10th, nth and 12th dorsal and 1st lumbar 
segment) . 

Gluteal Reflex. — This consists in contraction of the glutei on ver- 
tical stroking of the buttocks (4th and $th lumbar segments). 

Cremasteric Reflex. — Quick retraction of testicle upon stroking 
inner and upper part of thigh. (Not dartos contraction.) 

Caution. — All reflexes are best elicited when the patient's attention 
is diverted. The superficial reflexes merely prove the integrity of the 
region governing them. 

Babinski's Toe Reflex. — This consists in deliberate dorso-extensioD 
and separation of the toes and especially of the great toe, followed bv 
dorsi-flexion of the ankle joint, when the sole is gently or firmly 



*The real test symptom is contraction of the quadriceps muscle rather 

than actual movement Of the foot Hence the examiner's free hand should 

be placed upon the muscle. 






53° 



MEDICAL DIAGNOSIS. 



stroked with a quill point, finger nail, etc. It is usually associated with 
disease involving the pyramidal tracts and in any event is pathologic. 
It is said that in healthy young children not yet able to walk a similar 
but more rapid response is obtainable. 

Plantar Reflex. — The chief value of this sign lies in its constancy 
in health and frequent absence in hysteria. If the sole of the foot, thor- 
oughly dried, be stroked, the patient's attention 
being diverted, his position supine, the knee 
and thigh semiflexed with the leg in outward 
rotation, plantar flexion of the toes beginning 
with the four outer, and dorsi-flexion of the 
ankle result {2d and $d sacral segments). 

Oppenheim's Reflex. — This is a Babinsky 
reaction elicited by forcibly stroking ths inner 
border of the tibia. Gordon applies deep 
pressure to the calf muscles. 

Adductor Jerk. — Abduct thigh and tap 
adductor magnus tendon. Adductor contrac- 
tion may occur on both sides (crossed adductor 
jerk) in conditions of high reflex irritability 
and under the same conditions one may obtain 
knee clonus (clonic contractions of quadri- 
ceps). Extend leg and push patella sharply to 
the front, maintaining pressure for a considera- 
ble period. 

Organic Reflexes. — These involve chiefly 
respiration, deglutition, micturition and defeca- 
tion, and a full consideration of their compli- 
cated mechanism is out of the question in a 
volume on medical diagnosis, and are best considered in relation to the 
symptomatology of the individual diseases. 

Defecation. — To test the action of the rectal sphincter a digital 
examination is necessary, the strength of the resistant or grasping 
contraction being noted. In health contraction follows a prick of the 
anal region. Rectal incontinence may be met with in all conditions 
associated with coma or profound toxsemia such as typhoid, as well 
as in certain organic nervous diseases. There is sometimes a true 
reflex spasmodic incontinence. 

Micturition. — Dribbling of urine usually means overfilling of the 
bladder and calls for the use of the catheter; a true reflex incontinence 




Plantar re- 
flex. Upper plate shows 
normal reflex plantar 
flexion. Lower:— Dorsi- 
flexion of great toe. (Ba- 
binsky's sign.) 



THE EXAMINATION OF THE MUSCLES. 



531 



and nerve- 
lesions. 
Lack of 
tone. 



Loss of 
power. 



R. D. 



Faradic 
test. 



may exist such as is seen as a temporary phase in young children. 
Both rectal and vesical centres are in the lower lumbar (4th and $th) 
and upper sacral {1st, 2d, 3d portion of the cord). 

THE EXAMINATION OF THE MUSCLES.— The tests of paral- 
ysis are suggested by the defects noted under segmental lesions, page 
543, or under discussion of the special nerves involved. A peculiar 
lack oj tone is noticeable in a paralyzed limb even though the patient be 
unconscious and muscular atrophy is readily detected by observation, 
careful measurement and palpation. With this should be considered 
the question of power and electrical reactions as in certain diseases a 
spurious hypertrophy appears. 

Electrical Tests. — The reaction oj degeneration. Faradic and 
galvanic batteries are required together with the usual appliances for 
controlling and applying the current. The muscles shoidd first be tested 
for faradic excitability. Having wet both electrodes with salt water 
a weak current is applied, and, with the indifferent electrode over the 
sternum or between the scapulae, the smaller electrode is applied succes- 
sively to the motor points of Erb and the resulting tonic muscular con- 
traction and the increase of current necessary to produce it is noticed. 
Corresponding points on opposite sides of the body should be tested 
in alternation. The galvanic current. The indifferent electrode (the 
larger) should be positive, normal electrode negative. These are applied 
as in the faradic test and the current is first closed and after a moment 
again opened, gradually increasing the current until muscular contraction 
follows the closure of the circuit this constituting cathodal closure con- 
traction (CaCC). The switch is then thrown to change the direction 
of the current, the intensity of which must remain the same and the test 
repeated when muscular contraction will represent a nodal closure con- 
traction (ACC). The comparative promptness and strength of con- 
traction must be carefully noted. Further tests are not necessary but 
the opening contractions may be noted in the same manner. 

Significance of Electrical Reactions.— Normally the response 
should be prompt and decided to either electrode of the faradic current 
and should continue during its passage. If the contraction be sluggish, 
or absent, if it diminishes or disappears, it indicates disease. So also 
in the case of the galvanic current, the reaction following cathodal closure 
should occur with a less current than is required for anodal closure contrac- 
tion but no Ionic contraction should occur while the current is passing. 
Similarly AnCC exceeds AnOC and tins in turn CaOC. The reaction 
of degeneration, Jiowcvcr, is represented by an AnCC which equals or 



Galvanic 
test. 



Cathodal 
closure con- 
traction. 



Anodal 
closure 
contrac- 
tion. 



1 rompt- 
ness oi 
reaction. 



LaCO 
A n CCj 
normal. 



53 2 



MEDICAL DIAGNOSIS. 



exceeds CaCC. Furthermore, in the case of the galvanic as in the 
Sluggish faradic, contraction may be delayed, sluggish or vermiform or be 

response. . _ , _ _ . , ..... 

entirely absent. R.D. signifies a loss of nutrition in the motor nerve 
due either to disease of a trophic centre or the nerve itself and is a promi- 




Fig. 209.— The motor points of Erb. 



THE EXAMINATION OF THE MUSCLES. 



533 



A. Anterior surface of arm, shoulder and hand. 



Deltoid. 

Musculo-cutaneous n. 
Biceps. 

Musculo-spiral n. 
Brachialis anticus. 
& 7. Median (the ulnar lies just internal 
to 6). 
Pronator radii teres. 
Supinator longus. 
Palmaris longus. 
Flexor carpi ulnaris. 
Flexor carpi radialis. 
Flexor profundus digitorum. 
Flexor sublimis digitorum. 
Same (2nd and 3rd). 



Flexor longus pollicis. 
Pronator quadratus. 

Median n. 
Abductor pollicis. 
Opponens pollicis. 
Flexor brevis pollicis. 
Adductor pollicis. 
Lumbricales. 
Ulnar n. 
Palmaris brevis. 
Adductor minimi digiti. 
Flexor brevis minimi dig 
Opponens minimi digiti. 
Palmar interossei. 



B. Posterior surface of arm, shoulder and hand. 



1. Deltoid. 

2. Triceps (long head). 

3. Triceps (external head). 

4. Musculo-spiral nerve. 

5. Supinator longus. 

6. Fxtensor carpi radialis longior. 

7. Extensor carpi radialis brevior. 

8. Extensor communis digitorum. 



9. Supinator brevis. 
10. Extensor carpi ulnaris. 
[i. Extensor indicis. 
[2. Abductor longus pollicis and extensor 

brevis pollicis. 
[3. Extensor longus pollicis. 
[4. Abductor minimi digiti. 
[5. Dorsal interossei. 



C. Motor points on the head and neck. 



Temporalis. 

Middle branch. (Facial) two lower 

(branch of upper above). 
Occipitalis. 
Retrahens aurem. 
Upper facial. 
Facial trunk. 

Posterior auricular nerve. 
Masseter. 
Splenius. 

Spinal accessory nerve. 
Sternocleidomastoid. 
Trapezius. 
Long thoracic nerve (serratus mag- 

nus). 
Circumflex nerve (deltoid). 
Brachial plexus. 
Erb's point (deltoid, biceps, brachi- 

alis anticus, supinator longus). 



17- 



Anterior thoracic nerve (pectoralis 

major). 
Phrenic nerve. 
Omohyoid. 
Sternothyroid. 
Frontalis. 

Corrugator supercilii. 
Orbicularis palpebrarum. 
Nasal muscles. 
Levator labii superioris. 
Zygomaticus major. 
Orbicularis oris. 
Hypoglossal nerve. 
Levator labii inferioris. 
Depressor labii inferioris. 
Depressor anguli oris. 
Lower branch of facial. 
Platysma. 
Sternohyoid. 



D. Motor points on the anterior aspect of the leg. 



Anterior crural nerve. 

Tensor fasci;e latse. 

Sartorius. 

Obturator nerve. 

< juadriceps (.common point). 

rectineus. 

Rectus Eemoris. 

Adductor longus. 

Adductor magnus. 

( rracilis. 

Crureus. 



t2. Vastus externus. 

13. Vastus Internus. 

14. Externa] popliteal nerve. 

15. Peroneus longus. 

10. Extensor longus digitorum. 

17. Tibialis anticus. 

[8. Peroneus brevis. 

u). Extensor hallucis longus. 

20. Extensor brevis digitorum. 

21. Dorsal interossei. 



Motor points on the postei 



jpect 



ih 



teg. 



1. Gluteus maximus, 

•. Sciatic nerve. 

3. Adductor magnus. 

,i. Semitendinosus. 

*. Gracilis. 

(1. Semimembi anosus. 

7, Biceps 1 lone, head I , 

s. Biceps (.short head). 



o. 1 tlternal popliteal nerve. 

to. External popliteal nerve. 

11. Gastrocnemius (outer head), 

ta, Gastrocnemius (inner head). 

1.;. Soleus. 

1 1. Flexoi longus digitorum. 

15. Flexor longus hallucis. 

ui. Posterior tibial nen e. 



534 



MEDICAL DIAGNOSIS. 



Signifi- 
cance of 
R. D. 



Tests. 



Discrimi- 
nation 
required. 



Grave or 
trivial. 



Active 

vs 
Passive. 



Causes. 



nent symptom of the flaccid palsies whether affecting cranial or spinal 
nerves. When R. D. is present the jaradic excitability is lost. 

CERTAIN PSYCHIC AND SENSORY DERANGEMENTS. 

Defective Memory and Mental Obtuseness. — A patient's memory 
should be noted in the preliminaries of case-taking, and he may be 
specially questioned in regard to what he has had for dinner or breakfast, 
his birthday, the number and ages of children, etc. Mere dulness 
or confusion of ideas such as is associated with a multitude of disease 
conditions will of course obscure memory, but should be ascribed to 
their true cause. In some instances it may be due to organic lesions 
of the brain, such as apoplexy, tumor, thrombosis, embolism, meningitis, 
senile degeneration or sclerosis, or true insanity, or on the other hand 
to mere anaemia or commonly to neurasthenia. Actual loss of memory 
is chiefly observed in the true insanities, chronic alcoholism and neu- 
rasthenia. 

Illusions, Delusions and Hallucinations. — An illusion is a 
faulty interpretation of an actual visual impression and is actually a 
visual parassthesia common to nearly all forms of delirium; a babe may 
appear an ogre, a poker a serpent, etc. 

Delusions are false and irrational beliefs, unsystematized in delirium 
and systematized in insanity. Hallucinations are sensory impressions 
lacking any objective basis, and it will be readily seen that these various 
mental derangements are mutually contributory. 

Delirium. — Is in itself divisible into active (wild or maniacal), 
passive (low, muttering). Furthermore, a delirium may be wholly 
nocturnal and in all acute diseases tends to assume that form or merge 
gradually into it during convalescence. Delirium tremens and the 
fully developed cases of typhoid fever illustrate respectively the active 
and passive type. Delirium aside from brain lesions indicates chiefly 
toxaemia or extreme exhaustion, but may be seen in hysteria and occa- 
sionally in epilepsy. 

Disturbances of Sleep.— Insomnia may occur in acute and chronic 
diseases, whether cerebral or general, or in neurasthenia or simple 
overwork. Early waking or frequent waking is quite general in old 
persons, night terrors and transient somnambulism are common in young 
children. Tea, coffee, tobacco, cerebral excitement, old age, and fatigue 
are the common causes of sleeplessness. 

Disturbances of Speech* — Normal speech depends upon the normal 

*See also p. 29. 



CERTAIN PSYCHIC AND SENSORY DERANGEMENTS. 



535 



Complex 

association. 



Anarthria. 



Syllabic 

scanning 

staccato. 

Confluent. 



Causative 
lesions. 



interaction of the senses of sight, touch, smell, taste, sound and muscle 
sense, together with intact association fibres, a normal memory and an intact 
motor mechanism. If any link in this chain be lacking a defect in speech 
results, often taking the form which corresponds to the particular 
function or subfunction which is deficient. Thus anarthria or dysar- 
thria may result from a defective motor tract or from the lack of power 
to perform the co-ordinate movement necessary to word formation. This 
is characterized by imperfect articulation of the Unguals 1 and t if the 
tongue be involved, or of the labials b, p and n which are replaced by 
f and v if the lips are affected. Palatal paralysis causes explosive p's 
and b 's and makes the voice itself nasal. 

Changes in Rhythm. — Syllabic speech (division of words into sylla- 
bles), scanning and staccato speech (explosive word utterance) is another 
form frequently observed in multiple sclerosis and occasionally in other 
conditions. Opposed to this is the confluent speech usually bulbar 
in origin. In general one may say that lesions involving the medulla 
and pons give rise to anarthria or dysarthria, whereas cerebral lesions 
cause speech defects of an entirely different type in which the perceptive 
centres and higher and more complex degrees of co-ordination are involved. 
The lower mechanism is of course dependent upon and subservient 
to the higher. 

Disturbances of Speech of Cerebral Origin. — Such are included 
under the general term aphasia which is divided into motor and sensory 
types, the former representing the higher emissive mechanism, the latter 
the power of receiving and reviving speech concepts, being largely 
dependent upon sight and hearing (auditory and visual centres). The 
motor speech centre (Broca's centre) in the inferior third left frontal 
convolution and the articulation centre in the inferior anterior central 
convolution govern motor speech and either may be affected independ- 
ently of the other. A lesion of the left motor speech centre causes 
entire loss of voluntary speech, i.e. true motor aphasia, but does not 
affect automatic and emotional speech, the centre for which exists in 
both hemispheres. It is evident that motor aphasia logically includes 
the loss of power to utter given words (aphemia), to write words 
(agraphia), to use gestures (amimia) and the loss of power of musical 
expression, vocal or written (motor amusia and musical agraphia).* 



Motor 

vs 
Sensory 



Broca's 
centre (on 
opposite 
side in left 
handed 
persons^. 



Automatic 

centres. 



Amimia 
ami agra- 
phia. 



# Ataxic aphasia covers error in form without articulation defects or any 
evidence of sensory aphasia beyond slight or marked errors in the pro- 
nunciation of woids. ami is a form o!" aphasia usually seen in attacks that arc 
partial or during the process of recovery. The term is sometimes applied 
to motor aphasia in general. 



536 



MEDICAL DIA GNOSIS. 



Word deaf- 
ness and 
word blind- 
ness. 



Paraphasia 
and para- 
graphia. 



In sensory aphasia the inability to perceive and interpret language 
is fundamental and therefore there must be an auditory aphasia or word 
deafness (loss of power to recognize spoken words), visual aphasia or 
alexia (failure to recognize or understand written or printed words, 
word blindness), and subdivisions of exactly the same sort as were 
referred to under motor aphasia. In paraphasia, word repetition, 
misuse and incoherence are the chief features and paragraphia repre- 
sents the graphic form of the same subdivision. 

Mind blindness and mind deafness represent an entire loss of 
visual or auditory memory, not only of words but of common objects 
and the faces even of near relatives, or in the second variety all power 
to recognize musical or other sounds disappears. Here again we find 
subdivisions such as apraxia or inability to recognize the use of objects, 
and alexia representing a failure of comprehension in reading.* Amne- 
sic aphasia expresses the difficulty in recalling voluntarily special words 
or classes of words. 

The Lesions Affecting Speech. — Motor aphasia — third left frontal 
convolution in the right handed or a subcortical lesion underlying 
Broca's centre. Visual speech — left angular and supramarginal con- 
volutions. Auditory aphasia — first temporal convolution, auditor} 7 
speech centre or afferent tracts. 

Lesions of the association fibres are of course frequently combined 
with others as in apraxia. Anarthria may of course result from lesions 
in any portion of the tract interrupting stimuli from the higher mechan- 
ism or affecting the centres in the medulla and pons or indeed the 
cranial nerves themselves. 

Method of Examination. — (a). Motor aphasia (aphemia), patient 
cannot speak voluntarily, read aloud or repeat words. If he cannot 
write voluntarily or by dictation or copy he has agraphia. If in speaking 
or writing he uses wrong words or is strikingly incoherent there is 
paraphasia or paragraphia, (b). Sensory aphasia. The patient 
cannot recognize words written or printed and read them silently even, 
or he cannot read them intelligently or correctly. This is determined 
by writing direct simple questions to be answered by the patient. If 
he cannot hear spoken words or understand them as indicated by his 
failure to perform some ordinary action at command he has auditory 
aphasia. 



Apraxia 
and alexia. 



Amnesic 
aphasia. 



Localiza- 
tion. 



Tests. 



* Another rare subdivision known as dislexia covers a peculiar mental 
fatigue accompanying reading and even for short periods unassociated with 
visual defects or pain. 



INVESTIGATIONS OF SENSORY FUNCTIONS. 



537 



Comment. — In testing for both visual and auditory aphasia the 
sight and hearing should be previously tested. 

Mind Blindness and Mind Deafness. — For testing the former one 
should use common objects such as a pencil, pen, pocket knife or coin 
and ask the patient to use them, i.e. to write, to open the knife, to open 
a book, etc. Mind deafness should be tested by the slamming of a 
door, ringing a bell, coughing, etc., etc. 

INVESTIGATIONS OF SENSORY FUNCTIONS.— The eyes 
of the patient should be bandaged and one should test, ist. General 
sensation. 2nd. Pain. 3rd. Temperature sense. 4th. Muscle sense. 

Touch. — The tip of a pen, quill, toothpick or pencil point and a 
lightly rolled bit of cotton, a feather or a camel's hair brush are necessary 
for determining variations in sensibility, the latter articles serving to 
eliminate the element of pressure. The patient must be instructed to 
immediately say "touch" when any stimulus is perceived and he must 
be frequently checked by omitting the touch though putting the question. 
Exactly similar areas on both sides should be systematically followed to 
avoid bungling and time consuming repetition. He should also be 
made to indicate with his finger the exact points tested, or distinguish 
between normal, diminished (hypcesthesia), absent {ancesthesia) , and 
excessive (hypercesthesia) response. Such changes may be unilateral 
(hemianesthesia), bilateral or even general or limited to a single member. 
As regards perception of stimuli they may be prompt or delayed, and 
finally we have to deal with various forms of perverted sensory percep- 
tion (paresthesia), amongst which are many of special sense and the 
so-called "aura" of epilepsy. A failure to correctly localize sensations 
is common in disease and subjective transference to the opposite side 
is called " Allochiria" 

Tactile Sense. — This may be tested by the esthesiometer or lacking 
that an ordinary hairpin or pair of blunted or guarded compasses. In 
this both pressure and contact are included and the two points should be 
separated according to the part examined and in conformity to the 
following table* of normal perception, inasmuch as one point may be 
felt when two are applied or vice versa. The distances necessary for the 
sensation of two points in actual contact may be abnormally increased. 
In testing contact or touch the pressure sense may be determined by 

* Lips. 3 nun. (\ inch). Tip of toes, checks, eyelids, temple. I a mm. 
(\ inch). Tip of tongue, 1 mm. {.\ inch). Tip of Bulgers, a mm. 
(.,'■■ inch). Tip of nose. 8 mm. ($ inch). Back of hands, 30 mm. (i\ 
inch). Forearm, leg, dorsum of foot. 40 mm. (if inch). Hack. 60 80 
mm. (2$ i\ inches.) Ann and thigh. 80 mm, (3$ inches). 



Caution. 



Tests. 



Testing. 



Be sys- 
tematfe. 



Varieties 
of sensory 
defects. 



Delayed 
sensation. 



Paresthe- 
sias. 



Referred 
sensation. 



Simple ap- 
pliances. 



Pressun 



538 



MEDICAL DIAGNOSIS. 



Caution. 



Ataxia. 



placing articles of different weight upon different portions of the body, 
always seeing that they are supported. Localization is readily tested 
by having the patient place his own finger upon any spot touched and 
the pain sense is determined by using a pen or pin. Temperature sense 
is tested most conveniently with test-tubes containing warm and cold 
water.* Any of the varieties of sensation above described may be 
increased and diminished, absent or misinterpreted. 

Muscle Sense. — For proper testing, articles of various weight but of 
similar form should be used, the portion of the body tested being 
unsupported. The tendinous or articular sense is tested by having the 
patient imitate any movements of extension or flexion or unusual posi- 
tion in which the other leg is placed and further have him assume positions 
as described. 

Ataxia is chiefly dependent upon the articular and muscle sense but 
also involves sight, touch and other factors necessary to the harmoni- 
ous action of muscle groups. It may affect either station, gait or other 
voluntary movements. The Test. The patient should be asked to 
touch the lobe of the ear of the opposite side, tip of the nose or a cer- 
tain finger of the opposite hand or in the lower extremities touch differ- 
ent points of the opposite members of the great toe. He should then 
be required to stand with heels and toes together; marked swaying or a 
jail indicating static ataxia (Brauch Romberg sign). If with the eyes 
open he cannot walk a straight line he has motor ataxia. If his gait is 
reeling and drunken (titubating) he has cerebellar ataxia and in this 
form the patient shows normal muscle sense and co-ordination if recum- 
bent, the difficulty being one of equilibration. 

Ordinary ataxia indicates cortical lesions or those of the pons crura 
and corpora quadrigemina, locomotor ataxia, transverse spinal lesions, 
ataxia, paraplegia, Friedreich's disease and syringomyelia. Stereoog- 
nosis. — The inability to recognize familiar objects by touch (parietal 
lobe) usually suggests a lesion of the parietal lobe. 

Significance of Sensory Disturbance. — Hemianesthesia oj hys- 
terical origin commonly affects the left side, is sharply defined and 
frequently complete even as to the special senses. Cortical hemian- 
esthesia is combined with hemiplegia and usually incomplete unless 
associated with an unusually large lesion or involving the optic thal- 
amus. Crossed hemiancesthesia associated with hemiplegia of the 
opposite side has been referred to as present in unilateral lesions of the 
cord (Brown -Sequard paralysis). Hemiancesthesia and hemiplegia with 

* Normally 6o° F. is called cold and 85 F. warm. 



Static 
ataxia. 

Motor 
ataxia. 
Cerebellar 
ataxia. 



Hysterical. 
Cortical. 



Unilateral 
spinal. 



TOPICAL DIAGNOSIS 



539 



crossed Oculo-motor paralysis indicates a lesion of the crus, and finally, 
combined haemianaesthesia and hemiplegia may occur as the result of a 
lesion of the internal capsule. Anesthesias oj patchy distribution suggest 
hysteria or neuritis and as between those mono-ancesthesias due to a 
spinal lesion and the rare cerebral form the former presents a sharp bound- 
ary line, the latter an anesthesia diminishing as the trunk is approached. 
As between hysteria and neuritis the former tends to disregard both 
segmental and individual nerve distribution, the latter is distinctly in 
accordance with them. Bilateral anesthesia without motor paralysis 
usually affects the lower portion of the body and is particularly com- 
mon in traumatic neuroses and hysteria. If the latter, it spares the ' 
skin of the genitals and a portion of the sacrum, if from the spinal cord 
it would almost invariably be associated with paralysis or other evi- 
dence of cord disease. 

Hyperaesthesia and Hyperalgesia.— The well known hysterogenic 
zones of hysteria and neurasthenia furnish the best examples.* It may 
also be encountered in rickets, brain tumor, as a zone above the anaes- 
thetic level in unilateral spinal hemiplegia, or may be associated with 
meningitis, neuralgia and various toxic disturbances of the nerves. 

Anaesthesia Dolorosa. — Is encountered in compression of the spinal 
cord in which it co-exists with analgesia but is associated with extreme 
pain. Analgesia and hyperalgesia may be encountered, the former 
suggesting hysteria and syringomyelia. 

TOPICAL DIAGNOSIS. 

CORTEX. — Certain cerebral tracts are silent, i.e., symptomless, 
or may yield only psychic symptoms; others permit direct localizing 
diagnosis. 

Monoplegia is the type and it may be limited to the head or an extrem- 
ity, or in the case of the former, be confined to a single organ. On the 
other hand the close proximity of motor areas may produce associated 
monoplegias such as those of arm and leg, or face and arm or incom- 
plete hemiplegias, but usually with primary or ultimate predominate 
involvement of one area. Complete cortical hemiplegia is possible, as a 
glance at the illustration will show, but is rare. All unilateral cortical 
lesions produce paralysis of the side opposite the lesion. 

Silent Areas. -The frontal lobe may be greatly damaged without 
symptoms as may the corpus callosum and corpus striatum, though in 

* Those an- chiefly, tlu* breast, ovaries (deep pressure), groin, spinal 

Column and patella. 

35 



Crus and 

internal 
capsule. 



Neuritis 
and hys- 
teria. 



Spinal 
vs 
Cerebral. 



Traumatic 
neuroses 
and hys- 
teria. 



Associated 
lesions. 



Cord com- 
pression. 



I ncomplete 

hemiplegia 
common. 



Opposite 

side at- 

fected. 



54Q 



MEDICAL DIAGNOSIS. 



Few local- 
izing signs 
in certain 
areas. 



right handed persons aphasia may indicate a lesion of .the left inferior 
frontal convolution, or agraphia one of the central convolution and it is 
probable that the corpus striatum is concerned in deglutition and con- 
tralateral muscle sense. A reference to the motor area s, fig. 210, will 
show the lesions that must follow irritation or destruction of any of 
them, i.e. opposite facial paralysis, brachial monoplegia, crural mono- 
plegia, hypoglossal paralysis, etc., bilateral combined cortical lesions 




otorArea.sH 
-Sensory Areas! 



Fig. 210.— Motor and sensory areas of cortex. All lying anterior to the Rolandic fis- 
sure and above temporo-sphenoidal lobe are motor. The localization method of 
Chiene is also shown. This is applied as follows:— Find in the median line of the 
skull between the glabella (g) and the external occipital protuberance (o), the fol- 
lowing points: The midpoint (m), the three-fourths point (t), and the seven-eighths 
point (s). Find also the external angular process (e) and the root of the zygoma (p) 
immediately above and in front of the external auditory meatus. Having found these 
five points, join ep, ps, and et. Bisect ep and ps at n and r; also bisect ab at c and 
draw cd parallel to am. The pentagon (acbrpn) corresponds to the temporo-sphe- 
noidal lobe, with the exception of its apex, which is a little in front of n. mdca cor- 
respond to the Rolandic area, containing the fissure of Rolando, and the ascending 
frontal and the ascending parietal convolutions, a is over the anterior branch of the 
middle meningeal artery and the bifurcation of the Sylvian fissure; ac follows its 
horizontal limb. The lateral sinus at its highest point touches the line ps at R. ma cor- 
responds to the precentral sulcus, and, if it be trisected at k and l, these points will 
correspond to the origins of the superior and inferior frontal sulci. The supramarginal 
convolution lies in the triangle hbc. The angular gyrusisat B. (Sherrington, Chiene 
and Grunbaum.) 



being extremely rare. Mere irritation would produce the peculiar 

Jacksonian phenomena of Jacksonian seizures, viz.: — clonic convulsions in seat 

epilepsy representing the motor point of maximum irritation and following in 

orderly succession the motor areas. This is usually unilateral though 

rarely bilateral through commissural transmission and is ordinarily 



TOPICAL DIAGNOSIS. 



541 




CRUS. 



MEDULLA & 
DECUSSATION 




Fig. 211.— Explains symptoms 
caused by lesions affecting the 
motor tract in the brain and cord. 

Lesion at a, B, or ( : monoplegia 
of opposite side. Lesion at l>: — 

hemiplegia of opposite side. Le- 
sion at E: OCUlO motor paralysis 
of same side, hemiplegia of oppo- 
site side. Lesion at f:— facial and 

abducens paralysis of same side, 

hemiplegia of opposite side. Le 

sion of tit anterior horns: — causes 

flaccid paralysis and lost knee 

jerks. I .esion at 2 : -spastic pai .il\ 
sis of muscles lulow lesion if pj 

ramidal tracts only are involverlor 

the lesion is incomplete; llaccid 
paralysis if lesion is complete. 
I .esion at 3 : causes I'.iow n Se- 

quard's parajj sis. 1. Normal coi d. 

(After \ an ( iehucliten, modified.) 



due to injury, rarely to paretic demen- 
tia. If the parietal lobes be involved 
there may be loss of sensation and of 
stereognostic sense on the opposite half 
of the body or ptosis (angular gyrus), 
conjugate deviation of the eyes or even 
visual aphasia and hemianopsia. The 
occipital lobe is so related to the optic 
tract as to produce hemianopsia, see p. 
554, visual aphasia or even mind blind- 
ness. The temporal lobe lesions chiefly 
produce sensory aphasia, or, if bilateral, 
sound deafness. 

Centrum Semiovale. — The struc- 
ture and anatomical position of this 
great tract of projection and association 
fibres makes its lesions present either 
cortical or capsular symptoms and in- 
cludes both marked sensory and the 
widest range of motor disturbances, in- 
cluding those of special sense. 

Optic Thalamus. — It is said that the 
diagnosis of an isolated lesion of this 
ganglion depends chiefly upon the loss 
of the facial expression of psychical emo- 
tion upon the opposite side, the voluntary 
facial innervation being retained, a con- 
dition rarely observed. Irritation symp- 
toms are sometimes present as in cortical 
lesions, as is crossed homonymous 
hemianopsia (pulvinar). 

Lesions of the Internal Capsule. — 
(Fig. 212.) Almost all projection fibres 
between the cortex and the periphery 
(sensory, motor, and special sense) pass 
through this narrow ami sharply defined 
area and any lesion entails serious con- 
sequences. The anterior limb is a symp- 
tomless area, but the angular portion 
(knee) is highly motor and lesions tin 



542 



MEDICAL DIAGNOSIS. 



Gendrin's 
type. 



Hemi- 
plegia. 



cause paralysis in the opposite hypoglossal and lower facial distribution, 
if left sided, aphasia. If in the posterior \ of the posterior limb patchy 
hcemilateral ancesthesia, and perhaps hemianopsia and auditory dis- 
turbances. If in the anterior § of the posterior limb there is hemi- 
plegia of the opposite arm and leg. In most instances the paralysis is 
extensive and results in a combination of these lesions, i.e., complete 
hemiplegia. The upper branches of the facial, the trunk muscles, 
those of the neck, eye, and of mastication are paralyzed only in 
bilateral lesions. 

The Crura. — At this level the mixed type of paralysis commences 
and extends throughout the pons and 
medulla, the relation of the pyramidal 
tract to the cranial nerve nuclei being 
such that the lesion may produce 
spastic paralysis of the lower segment 
(brachio-crural type) and a flaccid 
paralysis of cranial nerve areas. Thus, 
lesions of the cms are associated with 
hemiplegia with crossed oculomotor pa- 
ralysis, sometimes including partial pa- 
d ralysis of the 3rd and 4th nerves of the 
other side through basal exudate. The 
type of tegmental lesion is hasmiataxia 
with crossed oculo-motor paralysis 
(Osier). 

Lesions of the corpora quadrige- 
mina are characterized by flaccid 
{nuclear or tract) oculo-motor paralysis, 
3d and 4th nerves, stumbling gait and 
ataxia (cerebellar type).* 

Lesions of the Lower Pons. — The ordinary type of paralysis is 
crossed spastic hemiplegia, with paralysis of facial and trigeminus on 
side of lesion (muscles of mastication, anaesthesia of trigeminal distri- 
bution, facial paralysis). Abducens paralysis (external rectus same side, 
and internal opposite lesion), defective taste and articulation (facial and 



* The region is rich in nuclei and lesions may be unilateral or bilateral 
and involve the tegmentum (incomplete hemianaesthesia) , the optic tract or 
lateral geniculate body (hemianopsia) , the crusta (paralysis of opposite leg 
and arm or even hypoglossal and facial hemiplegia) or produce defective 
hearing through involvement of the median geniculate body (Jakob). 



Hemi- 
plegia 



Varies 
with site 




Fig. 212.— Topography o 
tract in internal capsule. 



SEGMENTAL PARALYSES. 



543 



hypoglossal fibres), brachio-crural hemiplegia of opposite side and 
perhaps ataxia, vertigo, or trismus are also encountered. 

Lesions of the Medulla Oblongata. — Here again lesions may be 
unilateral or bilateral. The type is:— brachio-crural hcemiplegia and 
hcemiancesthesia of the opposite side with tongue pointing towards lesion, 
or if the fillet be involved bilateral anaesthesia. Anarthyria or dysphagia 
results and the type of glosso-labio laryngeal paralysis may be present 
and is usually bilateral. Coarse lesions rapidly fatal. 



Coarse 
lesion. 



Involves 
lower cra- 
nial nerves. 



Lesions of the Cerebellum. — Though sometimes lacking symptoms May be 
if unilateral, the chief and commoner characteristics of involvement iess. 



C/austrum 




u 3 

Stnsory Bundle 
Optic Radial 



Auditory 



Fig. 



!I3. — Showing relative position of motor and sensory fibres in the in- 
ternal capsule. (After Monakow.) 



of the vermiform process are cerebellar ataxia (staggering, drunken 
gait), vomiting, headache, vertigo or even movements of forced body 
rotation. Nystagmus and optic neuritis are common. Inco-ordination 
is coarse and may be greatly diminished in recumbency with closed exes. 

SEGMENTAL PARALYSES.*— The paralysis of muscle groups is 
the basis of localization in diseases of the cord and peripheral nerve lesion. 
and the diagrams (209, 216) show the lack of correspondence between 
the point of nerve emergence and its segmental origin and the seg- 

* Starr, Mills, Sachs, Dana, Thorburn, Butler ami Osier. 



Ataxia ami 
vertigo. 



544 



MEDICAL DIAGNOSIS. 



mental sensory areas. So far as possible this topic will be dealt with 
on the basis of segment symptomatology preceded by a discussion of 
lesions affecting certain of the cranial nerves. 

The Tongue. — (Hypoglossal nerve). In bulbar palsies, and basal 
processes deviation of the tongue to the paralyzed side (genioglossus), 
loss of backward movement (styloglossus) or deviation towards the 
sound side when retracted, or paralyzed side when protruded, asso- 
ciated perhaps with atrophy, unilateral or bilateral (lingualis), may be 
encountered. 

The Uvula and Velum Palati. — (Pharyngeal plexus, possibly 7th 
nerve). Nasal voice and regurgitation of food through the nose indicates 




Decussation* 
of Pyramids ,' ^ 



I 




Fig. 214.— Illustrating the mechan- 
ism of crossed paralysis in pontine 
lesions. (After Hermann.) 



Fig. 215.— Ventral aspect of me- 
dulla oblongata. (After Edingerand 
Hermann modified.* 



bilateral palsy; deflection towards the sound side, unilateral palsy of the 
azygos uvulae. Food regurgitation and immobility in "ah" intonation 
(paralysis involving the levator palati). Food regurgitation and nasal 
speech are also seen in palato-pharyngeus paralysis (5th nerve). 

Pharynx and Larynx. — Choking in deglutition due to the entrance 
of food into the larynx may arise from the failure of epiglottis closure 
due to paralysis of the stylo-pharyngeus (glosso-pharyngeal nerve), or 
deficient downward movement due to paralysis of the constrictors 
(pharyngeal plexus). 



SEGMENTAL PAEALYSES. 



545 



:- / 




Vitx. 216.— Segments of spinal cord and their relation to the vertebral landmarks* 

The variation between the level of Origin of the spinal nerves and their point of 
exit is well shown. The numerals indicate the segments, those to the right the spinal 
nerves, and corresponding vertebra. 'The lettered nerves when grouped will be 

named in their order a, nerves to rectus lateralis, to rectus amicus minor, anasto- 
mosis with hypoglossal; b, anastomosis with pneumogastric; c, nerve to rectus .111 
ticus major; d, to mastoid and great auricular and transverse cervical; e. to trapezius. 

am'., seap. and rhomboid; F, supra-clavicular and supra-acromial; g, phrenic, lev. 
ang, scap. to rhomboid sub-scapular and sub-clavicular; h. to pectoralis major; i.pos 
terior thoracic, serratus magnus; i. circumflex; k, musculo-cutaneous; 1. median, i a 

dial, ulnar internal cutaneous and lesser internal cutaneous; m. ilio h\ pogastric and 

ilio-inguinal; n, external cutaneous and genito-crural; o, anterior crural; p, obtura 

tor; (|, superior gluteal; r, to pyril'ormis and gemellus superior; s. to gemellus in- 
terior and quadratus; t. lesser and greal sc iat u - ; u. to levator am; \ , 10 obturator int., 
to sphincter ani and coccyx, (Dejerine and Thomas.) 



546 



MEDICAL DIAGNOSIS. 




Hoarseness, aphonia or paralytic stenosis and the various faulty 
positions of the cords as shown in the illustration may be due to paraly- 
sis of the musculature (recurrent laryngeal nerve excepting for the 
crico -thyroid). 

Spasm or paralysis of the sterno-cleido-mastoid (spinal acces- 
sory, medulla, ist, 2nd, yd, cervical segments) may cause wry neck 
(spasm), the head being inclined to one side with chin raised and 
pointing to the opposite shoulder. If para- 
lyzed, face cannot be turned to opposite side 
or if bilateral the head cannot be raised from 
the bed in recumbency. 

Flexion, Rotation of the Head. — If the 
chin cannot be brought to the chest the 
rectus capitis anticus, major and minor 
are at fault. Failure of rotation can seldom 
be traced to the rectus capitis lateralis but is 
usually due to sterno-mastoid paralysis. 

Deficient Thoracic Respiratory Move- 
ment affecting elevation and lateral move- 
ments of the ribs suggests paralysis of the 
scaleni (lower cervical segments). 

Deficient Upper Spine Flexion. — Sug- 
gests lesions involving the longus colli (lower 
cervical s). Impaired power to raise chin may 
be due in part to a lesion involving the 
clavicular portion of the trapezius (spinal 
accessory) ; a depressed shoulder to a lesion of 
the middle portion; abduction of the scapula 
to a lesion of the lower portion (spinal acces- 
sory, 2nd and yd cervical segments). 

Loss of power to approximate scapulae 
indicates a lesion of the rhomboids (4th and 
5th cervical segments). 

Oblique Position of the Scapula. — The inferior angle approaches 
the median line, the bone is raised, the arm cannot be raised above 
the horizontal position and if stretched forward the scapula projects 
(alar scapula). This indicates paralysis of the serratus magnus (pos- 
terior thoracic nerve, $th and 6th cervical segments). 

Inability to Raise Arm though Shoulder Rises. — The latter is 
flattened from atrophy and a groove appears below the acromiom. 



Fig. 217.— Vocal cords. (Dia- 
grammatic mirror picture.) 

1. N or m a 1 p o si ti on in 
breathing and phonation re- 
spectively. 

2. Adductor paralysis 
(left) 2'. Bilateral adductor 
paralysis. Both in phonation- 

3. Unilateral abductor 
(left) and 3' bilateral ab- 
ductor paralysis both during 
breathing. 

4. Left recurrent paraly- 
sis phonation, 4' same in res- 
piration, 4" recurrent bilat- 
eral in both respiration and 
phonation. 

5. Arytenoid paralysis 
phonation. 5/ Thyroaryte- 
noid paralysis, phonation 5" 
Arytenoid and thyroaryte- 
noid paralysis. 



SEGMENTAL PARALYSES. 



547 



This indicates paralysis of the deltoid, any one of the three divisions 
of which may be separately affected {circumflex nerve, 4th, $th and 
6th cervical segments). If the arm cannot be moved outward, the 
infraspinatus is involved (suprascapular). If writing is difficult the 
teres minor is involved (circumflex), if the arm cannot be moved in- 
ward a lesion of the subscapularis is suggested (subscapular nerve). 
All three represent the 4th, 5th and 6th cervical segments. 

Impaired Lateral Trunk Movement. — With failure of dorsal 
spine extension and backward movement of the arm indicates a lesion 
involving the latissimus dorsi (subscapular and 6th, 7th cervical seg- 
ments, chiefly). 

Inability to Firmly Proximate the Volar Surfaces with Ex- 
tended Arms. — Suggests a lesion of the pectoralis major (anterior 
thoracic nerve, ph, 6th and 7th cervical segments). 

Inability to extend arm against resistance indicates a lesion of 
the triceps which is associated with liability to subluxation of the 
humerus, spontaneous or induced by slight causes (musculo- spiral, 6th, 
jth and 8th cervical segments). 

Impaired flexion of the arm suggests a lesion of the biceps 
(musculo-cutaneous, 4th, $th and 6th cervical segments), if flexion and 
pronation are both deficient the supinator longus is to be considered. 
The arm is usually spindle shaped from atrophy of the muscle (musculo- 
spiral, 4th, 5th and 6th cervical segments). 

Deficient supination with arm extended indicates supinator brevis 
involvement (musculo -spiral, $th cervical segment). 

Failure of dorsal flexion and abduction of the wrist with 
atrophy of the forearm indicates a lesion of the extensor carpi radialis 
longus and brevis; if adduction also fail from paralysis of the extensor 
carpi ulnaris drop wrist is produced; if extension and abduction of the 
first phalanges fail a paralysis of the three extensors of the fingers is 
indicated (for all musculo -spiral, yth cervical segment). 

Impaired flexion of the fingers and wrist suggests paralysis of 
the flexors of the wrist and fingers. The median nerve supplies the flexor 
carpi radialis, palmaris longus, ilexor sublimus digitorum, and. in part. 
the deep flexor of the digits, the ulnar supplying the remainder of the 
last named and the Ilexor carpi ulnaris, all being related to the 8/// cer- 
vical segment. 

Failure of Abduction and Adduction of Fingers. Suggests a 
lesion of the interossei ami lumbrieales (ulnar and median. Sth 
dud i.v/ dorsal segments). With extension of the first phalanges and 



548 



MEDICAL DIAGNOSIS. 



flexion of the 2nd and 3rd and deep interosseus spaces it forms the 
claw hand {main en griff e). 

Atrophy of the Ball of the Thumb. — An impairment of its exten- 
sion and adduction suggests a lesion of the extensor pollicis brevis and 
thenar muscles to which is added flexion of the second toward the first 
phalanx if the extensor pollicis longus is involved, with deficient 
abduction if the abductor pollicis longus is affected (for all, musculo- 
spiral nerve, first dorsal segment) . If flexion of the thumb fails and atrophy 
is present the "ape hand" is formed (abductor brevis pollicis, flexor 
brevis and adductor pollicis). The opposing movement may be absent 
(opponens pollicis and in part flexor brevis and abductor pollicis 
brevis) or flexion of the terminal phalanx may fail from paralysis of 
the flexor pollicis longus. The nerve supply is from the median and 
ulnar and first dorsal segment. 

Lower spinal lordosis with deflexion towards sound side in unilateral 
lesions indicates a lesion involving the erector spinae, sacro-lumbalis 
and longissimus dorsi {dorsal nerves, 2nd to 12th dorsal segments). 

Lordosis with Prominent Nates and Abdomen. — Inability to rise 
up from a dorsal recumbent position without assistance from hands 
indicates a lesion of the abdominal muscle group {dorsal nerves, 2nd to 
12th dorsal segments). 

Imperfect lateral movement of lower spine suggests quadratus 
lumborum involvement {lumbar nerves and segments). 

Loss of. Thigh Adduction. — (Thigh rolls outward), indicates paral- 
ysis of the adductors {obturator nerve, great sciatic and crural, yd 
lumbar segment). 

Imperfect flexion of the thigh suggests involvement of the sar- 
torius {crural nerve, yd lumbar segment). 

Impaired Leg Extension. — Involvement of the quadriceps femoris 
{crural, yd lumbar segment). 

Impaired flexion and difficulty in rising from the horizontal position 
suggests involvement of the ilio-psoas {crural nerve, 4th lumbar seg- 
ment) and the tensor fasciae femoris {superior gluteal, 4th lumbar seg- 
ment). 

Impaired Outward Rotation. — Leg being turned inward suggests 
involvement of the external rotators, pyriformis, gemelli and quadratus 
femoris. supplied by sacral plexus, $th lumbar segment, as well as the 
internal and external obturators {obturator nerve, lumbar plexus). 

Complete loss of thigh extension and abduction with waddling 
gait and inability to climb indicates paralysis of the gluteal muscles 



BRACHIAL PLEXUS PARALYSIS. 



549 



(inferior gluteal nerve, sacral plexus, first and second sacral segment 

and superior gluteal, ist and 2nd sacral segments). 

Impaired flexion perhaps associated with hyperextension 

through action of quadriceps and hyperflexion in standing, points to a 

lesion affecting the biceps, semitendinosus and semimembranosus. 
Deficient foot flexion, i.e. patient cannot stand on tiptoes or raise 

heel indicates gastrocnemius, plan- 
taris and soleus paralysis (internal 
popliteal nerve, $th lumbar seg- 
ment). 

Drop Foot. — Usually with ex- 
cessive knee and hip flexion with 
perhaps pes equinus or equinova- 
rus from contracture points to in- 
volvement of the anterior tibial 
muscles, i.e. tibialis anticus, ex- 
tensor digitorum and extensor 
longus pollicis (anterior tibial 
nerve, $th lumbar and ist sacral). 
Deficient Abduction. — Ten- 
dency to flat foot increased by 
contracture points to involvement 
of the peroneus longus (peroneal 
nerve, ist and 2nd sacrals). De- 
ficient abduction with resulting de- 
formities suggests involvement of 
the tibialis posticus posterior tibial 
nerve, ist and 2nd sacrals), and the 
peroneus brevis (peroneal nerve, 
ist and 2nd sacral segments). 

Adduction of Toes. — Paraly- 
sis of interossci with hyperexten- 
sion of first phalanges and flexion 
of the 2nd and 3rd (claw foot) 
Qterossei and Lumbricales (posterior tibial, 




Fig. 218.— Areas of anaesthesia following 
segmental lesions of spinal cord, the 
numbers shown corresponding to the af- 
fected segment. (Attn- Starr.) 



indicate involvement of the 
\st and 2nd sacral segments). 
Deficient Toe Flexion. 



Impaired power to push fool off ground 



indicates a lesion of the adductors, tlexor brevis and abductor hallncis. 
The segmental sensory localization is indicated by tig 2t8, 
BRACHIAL PLEXUS PARALYSIS. Paralysis is usually the re 



55° 



MEDICAL DIAGNOSIS. 



Klumpke's 
type. 




Drop wrist. 



suit of traumatism or compression of some sort most commonly below 
the clavicle, and may be either partial or complete. If only the upper 
portion be involved the lower muscle groups (forearm and hand) may 
Erb's type, with the exception of the supinator longus escape (Erb's type). Com- 
lesions involve a total motor and sensory paralysis of the arm 
and there is a lower arm type in which 
forearm extension and use of the hand are 
lost, the triceps, flexors of the wrist, prona- 
tors, extensors and flexors of the fingers 
being involved and frequently ocular signs 
of involvement of the sympathetic. 

CERTAIN SPINAL NERVES.— Oc- 
cipital. — Neuralgia, anaesthesia. 

Posterior Thoracic. — Arm cannot be 
raised above horizontal and rotated. Pro- 
jecting scapula (serratus magnus). 

Anterior Thoracic. — Inability to adduct 
arm (pectoralis major). 
Musculo -cutaneous. — Loss of elbow 
flexion power (biceps, brachialis anticus). Anaesthesia inner border of 
forearm. 

Circumflex. — Loss of outward rotation and elevation of arm (deltoid 
teres minor), third head of triceps. 
Suprascapular. — Impaired outward shoulder rotation and elevation. 
Musculo-spiral and Radial. — Paralysis from lead, arsenic or 
alcohol, tumor and crutch pressure and trau- 
matism or whatever cause is common and leads 
to the characteristic dropping of the wrist from 
extensor paralysis (drop wrist) so commonly 
seen in clinics. A factor in differential diag- 
nosis is the involvement or non-involvement of 
the supinator longus which is usually spared 
in lead poisoning. The triceps and anconeus 
are paralyzed, extension of forearm lost and 
there is wasting of the back of the arm. 

Median. — Abduction of thumb and flexion of thumb and first and 
second fingers lost. Thenar and anterior forearm atrophy usually marked. 
If forearm be flexed pronation is impossible. The thumb and index 
finger are approximated and there is paralysis of the abductor pollicis. 
It is seldom paralyzed alone. 




Fig. 220.— Claw hand. 



THE CRANIAL NERVES. 



551 




Fig. 221. 
Dropped foot. 



Ulnar Nerve. — Impaired abduction and flexion of hand (flexor 
carpi ulnaris and part of flexor sublinis digitorum) wasting of ball of 
little finger and interosseous spaces, one cannot cup the palm, nor span. 
The ring and little fingers are "clawed" ("claw hand," 
"main en griffe"). Paralysis of their lumbricales and 
interossei prevent flexion of the proximal or extension 
of the distal phalanges and the unopposed muscles 
exaggerate the position. 

Intercostal Nerves. — Violent neuralgic pains or 
other symptoms of irritation, sometimes herpes zoster 
along the course of affected nerve, anaesthesia. 

Crural Nerve. — Patient cannot stand or walk and 
tendon reflex is absent (psoas-quadriceps extensor). 

Obturator. — The obturator plexus is a frequent seat 
of pain, referred to the inner side of the thigh and knee 
joint in disease of the mid-lumbar, sacro-iliac and hip joints. Obturator 
paralysis means loss of adduction. 
Sciatic. — Paralysis of leg flexors, foot and toe, sciatica. 
Peroneal Nerve. — Foot drop from paralysis of flexors of foot or 
leg by contracture, talipes equinus or varus may appear. 

Tibial Nerve. — Paralysis of calf mus- 
cles, loss of foot extension or toe flexion. 
Talipes if contractures occur. 

THE CRANIAL NERVES.— Irritation 
produces excess or perversion of junctional 
activity, i.e. spasm, tremor, pain, itching, 
formication, etc., destructive lesions, ultimate 
loss of function, muscle atrophy, etc., inas- 
much as a peripheral neurone is thus dis- 
turbed or destroyed. The nucleus of the 
cranial nerve corresponds to the nutrient 
anterior horn cell of the spinal nerve. 

OLFACTORY NERVE.— Test— Apply 
to each nostril in turn bottles containing 
well known aromatic oils (peppermint, cloves, assafetida, bay, etc.) and 
have the patient describe the odor. Any inflammation, degeneration, 
necrosis, traumatism or pressure affecting the terminal filaments, bulb or 
tract Jrom the uncinate gyrus and thalamus to the Scltncidcrian membrane 
produces lessened, absent (anosmia) or perverted {parosmia) junction. 
These constitute also symptoms of hysteria, epilepsy, locomotor ataxi 




Irritation 



Destruc- 
tion. 



Simple 
tests. 



Anosmia. 



552 



MEDICAL DIAGNOSIS. 



Hallucina- 
tions. 



Past iritis. 
Acute iritis. 



Syphilitic 
iritis. 



Oculo- 
motor and 
sympa- 
thetic. 



Local 

disease. 



Early eye 
changes in 
tabes. 



and insanity (hallucinations of smell). Trigeminal paralysis and cer- 
tain catarrhs act no doubt by lessening the secretion. 

THE EYE, ITS REFLEXES AND THE OPTIC NERVE.— 
The Pupil. — The shape, equality of the two sides and the mobility or 
response to light and accommodation should be noted. Irregularities 
in outline suggest chiefly adhesions from past iritis. In acute iritis 
the color of the iris is turbid and greenish, the corneal circumference 
showing an hyperaemic zone. Difference in the color of the iris of the 
one eye as compared with the other is especially important in detecting 
iritis in eyes normally dark. The commoner causes of iritis are gout, 
rheumatism, trauma and syphilis and 
the first two are usually of the unilateral 
relapsing type, the last is bilateral, be- 
longs to the period of secondary infec- 
tion and seldom recurs. 

Inequality. — Even in healthy per- 
sons, considerable inequality occurs 
but pathologic irregularity is important 
and may represent either unilateral 
contraction or dilatation. The former 
(myosis) may be due to iritis, oculo- 
motor irritation or paralysis of the 
sympathetic, but occurs normally with 
suspended reflexes, e.g. in sleep. The 
latter {mydriasis) indicates conversely 
sympathetic irritation (aneurism of the 
arch, goitre, enlarged glands or other 
swelling, etc.) or oculo-motor paralysis. 
Furthermore, glaucoma, cataract, disease of the optic nerve and the 
retinal haemorrhage of albuminuria may be the causes of dilated pupil, 
both unilateral and bilateral. 

Persistent mydriasis is frequently noted in cases of hysteria, high 
myopia, neurasthenia, severe dyspnoea or actual asphyxia, cerebral 
abscess, hemorrhage, thrombosis and tumor, exophthalmic goitre, epi- 
leptic coma, catalepsy, melancholia, mania and active delirium, late 
meningitis, in aortic regurgitation, shock, fear or strong emotion 
generally, nausea, and in poisoning by such mydriatics as tobacco, 
alcohol, nitrous oxide gas, cocaine, choral, chloroform, ether, duboisin, 
hyoscin, scopolamin, 'stramonium, conium and belladonna. Certain 
cases of locomotor ataxia show as an early symptom dilated pupils and 




223.— Nuclei of cranial nerves 
in medulla oblongata. (After Erb. j 
The nuclei by Roman numerals. 
The nerve roots are similarly shown 
at the side. 

1. Brachium pontis. 

2. Brachium conjunctivae. 

3. Cerebellar peduncle. 

4. Eminentia teres. 

5. Striae acousticae. 

6. Ala cinerea. 



EYE REFLEXES. 



553 



ptosis with beginning atrophy of the nerve head in many instances and 
such cases run a course marked by long delay in the development oj 
ataxic and -paralytic symptoms. 

Contracted Pupils.— The following conditions may be associated 
with persistent bilateral miosis. Locomotor ataxia, general paresis, 
high hypermetropia or astigmatism, disseminated sclerosis, tumor, 
hemorrhage, meningitis, inflammation or degeneration of the brain or 
cord, uraemia, sunstroke (early stage), photophobia, congestion of the 
iris, etc. 

The primary action of ether, chloral, opium, eserine and pilocarpine 
is miotic and general venous congestion, unless associated with marked 
dyspnoea, may produce bilateral pupillary contraction. 

Unilateral Contraction. — Marked unilateral contraction aside from 
adhesions, iritis, paretic dementia and apoplexy is an important sug- 
gestive sign of a serious lesion of the brain, cervical cord or any region 
involving the motor oculi or sympathetic. Mediastinal tumors, aneu- 
rismal, glandular or malignant, with their pressure effects, account for 
many cases, and should be constantly borne in mind. In not a few 
case? an artificial eye has puzzled the careless physician. Tuberculous 
cases often present persistent slight dilatation, usually unequal and 
sometimes merely transient. 

Hippus. — An oscillating contraction and dilatation of the iris on 
sudden exposure to light is of little clinical importance, though often 
associated with nystagmus and sometimes present in disseminated 
sclerosis. 

EYE REFLEXES. — Light response: Proper testing demands that 
the consensual light reflex be remembered and involves both light and 
accommodation reactions, that of convergence being of no special im- 
portance. The best methods demand the use of the ophthalmoscope in 
a darkened room and the use of such a + lens as will enable the 
observer to see the magnified pupil as the mirror flashes the light upon 
the eyes. Each must be separately tested and the patient should look 
slightly to the right or left of the observer to avoid the accommodation 
reaction. As a matter of fact there is normally a sympathetic reaction 
of the other pupil (consensual reaction). 

Reaction to Accommodation.* -Ordinarily contraction of the 
pupil attends accommodation jor near vision and in locomotor ataxia 
and general paralysis especially, this re/lex persists though that for 

light is lost (Argyll Robertson pupil). In general such a pupil Indicates 
♦ Probably inseparable from the convergence reaction. 



Often a 
serious 
symptom. 



Trivial. 



Direct ami 
indirect. 



Argyll 

pupil. 



554 



MEDICAL DIAGNOSIS. 



Course of 
fibres. 



Visual 
fields. 



V 



C3* 



a lesion of the optic tract or Meynert's fibres, whereas fixed contraction 
indicates a lesion of the centre or motor oculi. 

OPTIC NERVE. — The tiny primary optic neurones* receive the 
visual impressions through their dendrites, the retinal rods and cones, 
the axones passing to the visual centres in the optic thalamus (pul- 
vinar), corpora quadrigimini and ge- 
niculate bodies, through the posterior 
portions of the internal capsule and 
finally, in the optic radiation, to the 
cuneus. The axones from the nasal 
sides of the retina, which represent the 
outer and larger portion of the visual 
fields, cross and pass to the centres of 
the opposite side. Those of the temporal 
portion (inner and lesser visual field) run 
direct to the centres of their own side. 
The point of decussation (chiasma) 
therefore represents all fibres. 

Anterior to it lie the mixed fibres for 
the respective halves of each eye; poste- 
riorly, those for the outer segment of 
the eye of the same side (nasal visual 
field) and the inner portion of the op- 
posite eye (temporal visual field). 

Interference with these fields Causes a temporal hemiopia by interruption 

of the nasal fibres, at d, e or / a lesion 

Hemiopia. hemianopsia and the Variety of the will produce right homonymous 

1 . . . hemiopia. 1 and 2 represent the 

hemianopsia and the naming Of the retina; 3 and 4, optic nerves; 5, the 

„ . j 7 r 77 . ,■■ chiasm; 6 and 7, optic tracts; 8, the 

affected VtSUal field represent the pa- pu lvinar; 9, the primary optic cen- 

Herts view point; hence the variety of ^SJ&£u.^SLS3^^A 
hemiopia is the reverse of the retinal ^ ^ x ^ tx ^tl^ v J^ 

field affected, i.e. temporal retinal change retinal distribution and visual fields 

. . are indicated by the solid red (left 

= tiasal hemianopsia, etC.f The COfl- tract) and dotted black (right tract) 

dition may be unilateral or bilateral, 

total, partial or concentric, affecting corresponding halves (homony- 
mous), both temporal or both nasal fields (heteronymous), or even both 
upper or lower halves (superior or inferior altitudinal). 

A lesion may occur at any point from and including the retinal surface 
to the cortical centres. If unilateral and in front of the chiasm blindness 

* The true optic nerve (Church and Peterson). 

t Hemiopia, hemianopsia, hemianopia are synonymous terms. 






Fig. 224— Course of optic nerve 
fibres from cortex to retina showing 
relation of visual fields. (After 
Sahli, slightly modified.) 

Explanation. A lesion at a pro- 
duces unilateral blindness, at bore 



Effect of 
lesions. 



OPTIC NERVE. 



555 



of that eye follows. If at the chiasm either the anterior or posterior 
angle (nasal £ of retina) is usually affected causing bitemporal haemi- 
anopsia. If the outer portion only be involved unilateral or bilateral 
nasal hemianopsia follows. A lesion behind the chiasm if on the right 
side causes left hemianopsia, if on the left right hemianopsia.* Pre- 
cisely the same phenomena occur if a lesion affects the more central 
tracts, save that the difficult "hemianopic" (Wernicke's) pupillary reac- 
tion is to be considered. Test. Carefully note size of pupils by plane 
mirror illumination in dark room, then with the ophthalmoscope direct 
a narrow, strong beam of light upon the blind portion of the retina. If 
pupillary contraction occurs the lesion is posterior to the corpora quad- 
rigemina.f It should be remembered that (a) tract lesions ordinarily 
produce hemianopsia, (b) nerve lesions total blindness and that (c) cen- 
tral vision is retained in unilateral tract lesions because the macula of 
each eye receives fibres from both optic tracts. 

Diagnostic Significance. — Disturbances of vision due to tract lesions 
are usually associated with gummata, new growths and syphilitic and 
tuberculous meningitis. 

Associated Lesions. — Incomplete hemianopsia with aphasia and 
mind or word blindness indicates a cortical lesion. Angular gyrus 
lesions are suggested by impaired vision in one eye associated 
i with a contracted visual field of the opposite eye. Athetosis sug- 
gests a pulvinar lesion; altitudinal hemianopsia, a lesion of the upper 
\ or lower part of the chiasma, or if unilateral, a lesion of the cuncus. 
\ Hysterical hemianopsia is associated with the usual stigmata, hcmian- 
' cesthesia, insensitive conjunctiva, and more often takes the form of con- 
tracted fields and alteration of color vision areas. Fugitive hemianopsia 
may accompany migraine. Total unilateral blindness may be due to 
a destructive lesion of the occipital lobe or optic >icrve. Bilateral lesions 
of the cuneus or optic nerves or total destruction of the chiasma will cause 
bilateral blindness. High refractive errors of long standing may be 
{ associated with unilateral loss of vision. 

Color Fields.- The limits of color vision may be indicated by con- 
centric circles, the inner and least being for green, then red, blue and 

finally white. Aside from actual nerve lesions color perception is 

greatly modified in toxic amblyopias (tobacco, etc.) and the neuroses. 

* For example, a Lesion of tin- right tract cuts off the retinal impressions 
a of its own temporal \ and the opposite nasal half of the retina, hence left 
visual tirMs are lost for both eyes (left homonymous hemianopsia). 

t As the pupillary reflex sensory fibres run in the nan nearly to thi 
pora any Lesion anterior means an interrupted reflex arc. 

3<5 



Wernicke's 

localizing 

reaction. 



General 
laws of lo- 
calization. 



Causes of 
tract le- 
sions. 



Cortical 
lesions. 
Angular 
gyrus. 



Pulvinar. 

Chiasma 
and cuneus. 
Hysteria. 



Total blind- 
ness. 



Vary 
color. 



ith 



Modify ing 
conditions. 



556 



MEDICAL DIAGNOSIS. 



Transitory 
blindness. 



Total 

blindness. 



Lacking 
special in- 
struments. 



trilateral 

vs. 
Bilateral 



Scotomata. 

Muscse 

volitantes. 



Amblyopia, Amaurosis. — Amblyopia and amaurosis describe 
respectively, the one, impairment, the other, total loss of vision 
without actual lesions, but in the latter associated with various 
neuroses and toxaemias. Amaurosis is alarming but usually transit- 
ory, lasting from a few hours to several days. It suggests uraemia, 
diabetes, severe and especially acute anaemias, spasmodic contraction of 
retinal vessels, hysteria and migraine, and has followed the adminis- 
tration of quinine and the salicylates, the over-use of alcohol and 
tobacco, cerebral trauma and lead poisoning * 

Testing Vision. — Acuity. — If total blindness be suspected the pa- 
tient should be asked to count the fingers of the physician as held before 
him at varying distances, failing in this he should be tested for light 
perception in a dark room.f (See also simulated blindness, p. 624.) 

The Visual Field. — Rough Test. — Squarely face the patient at a 
distance of eighteen inches. If the left eye is to be tested the right 
should be covered and the patient told to look squarely and fixedly 
at the right eye of the examiner whose left is closed. The latter then 
holds his open hand well off to the side but on a level with the eye and 
brings it inward, moving the fingers constantly until the patient sees 
them without moving the head or eyeballs; the same procedure tests all 
portions of the field and checks the patient's range with the presump- 
tively normal one of the physician. For more accurate or graphic delin- 
eation the various perimeters may be employed. 

Central Scotomata. — Loss of central vision or central amblyopia if 
unilateral is usually due to choroiditis or retinitis, if bilateral to chronic 
toxcemias and syphilis. Scotomata of color vision are best detected by 
the perimeter. J In migraine and certain conditions of cerebral men- 
ingeal irritation the so called "flittering" scotomata appear. These 
are "like a sunset cloud." Muscaz Volitantes. Little floating motes, 
specks or thread-like figures are common in over-strain, hysteria, 
anaemia, dyspepsia, eye-strain and various other conditions. 

* Unilateral amblyopia suggests either " amblyopia ex- anopsia " of stra- 
bismus or a preexisting deviation which has become straightened, or the 
lesions that may produce complete blindness, or affecting the angular and 
supra-marginal convolutions. 

f Minor disturbances are tested by the use of the well known Snellen's 
test types. 

X A rough test consists in holding before the patient's eyes at a distance 
of i\ to 2 feet a black square of cardboard with a central white spot. While 
his eyes are fixed on the white spot a black strip carrying a green or red 
spot or wafer at its extremity is placed quickly at the outer side of the 
white. If not seen it indicates central color scotoma. 



I 



PLATE V 




Fig. I. Normal Fundus 



Fig. 2. Embolism of the Central Artery 




Fig. 3. Thrombosis of the Central Vein 
{So-called Hemorrhagic Retinitis) 



Fig. 4. Albuminuric Retinitis 



From Thorington-s "Ophthalmoscope and How to Use It-) 



DESCRIPTION OF PLATE V. 

Fig. i. — Normal Fundus of Left Eye. 
Direct Method. Disc is round, having light-colored centre, distinct 
margins and yellowish-red intermediate zone. Choroidal ring almost 
complete and slightly more pigmented to the temporal side. Two 
cilio-retinal vessels on the lower outer edge of disc passing toward the 
macula. The crescentic fovea centralis, with surrounding blood-red 
area, is unusually well shown and most typical at this young age. 
Veins and arteries are slightly to the nasal side of the disc. The 
arteries cross the veins on the disc, but in the periphery the veins cross 
the arteries. 

Fig. 2. — Embolism of the Central Artery of the Left Eye. 
Direct Method. 
Large, oval-shaped, blanched area, which includes the disc and 
macula. Cherry-red spot at the macula. Intermediate zone of the 
disc shows apparently normal except for a faint fogginess. The arter- 
ies are almost empty and the smaller ones have the blood stream 
broken in different places. The arteries have lost their light streak. 
The veins are slightly distended, but not tortuous; the light streak is 
almost lost in the veins, but can be faintly seen. 

Fig. 3. — Thrombosis of the Central Vein of thf Left Eye. 
(Apoplexy of the Retina, Hemorrhagic Retinitis.) 
Fundus Changes. Left Eye. Acute papillitis. Disc very much 
swollen and apex seen with +4 D. and fundus without any lens at the 
sight hole. Arteries small and very few of them in view. The veins 
are very tortuous, looking like half hoops or serpentine, hence the con- 
dition as described in the text of " Medusa Nerve." The light streak 
in the veins is conspicuous at the top of each loop. The hemorrhages 
are of all sizes and shapes and shades of red. 

Fig. 4. — Albuminuric Retinitis. Bright's Disease. Right Eye. 
Direct Method. 
Fundus Changes. Swollen disc, striated edges; exudation (" snow- 
banks ") about its edges with two areas above and one below the disc. 
Macular figure unusually well marked. Many scattered and flame- 
shaped hemorrhages seen in the periphery aud about the disc. Vessels 
about the disc show effusion into their sheaths by the white edge at 
each side of the vessel. The disc resembles that of choke d disc in 
brain tumor, but the "snow banks" and macular figure are almost too 
conspicuous for such a diagnosis. 



OPHTHALMOSCOPY. 



557 



Important. 



Unilateral 

vs. 
Bilateral. 



Brain 
tumor. 



Other 

associated 

lesions. 



Optic Neuritis. — (Choked disc, papillitis). Amongst the varied 
lesions shown by the accompanying plates optic neuritis easily holds 
first place. It occurs in from 80-90% in all brain tumors, is usually 
found in meningitis, especially if that be basal and is not infrequently 
present in cerebral abscess. In all cerebral lesions it is likely to be 
bilateral, though more advanced in one eye than in the other. If in 
such cases it is unilateral it is on the side of the brain affected. As 
regards the location of brain tumors in relation to the frequency of 
optic neuritis, it may be said that it is invariable in tumors involving 
the corpora quadrigemina, occurs in 90% of those at the base, parieto- 
occipital region and cerebellum, and with scarcely less frequency in 
those of the crura and frontal lobes. In the case of no region does it 
fail to appear in much less than 50% of the lesions. Amongst other 
causes are chronic nephritis, diabetes, hydrocephalus, sinus thrombosis, 
syphilis, lead poisoning, cysts, meningeal hemorrhage and trauma; 
rarely it is noticed in severe acute infections and sunstroke. Its char- 
acteristics are so well shown by the plates as to need no further 
description. (See also p. 579.) 

OPHTHALMOSCOPY.— Every physician should be able to use the 
ophthalmoscope at least so far as its findings relate to the common lesions 
aside from actual refraction errors. It often proves the master key 
of diagnosis in obscure cerebral lesions, syphilis, tuberculosis, loco- 
motor ataxia and arterio-sclerosis, and of prognostic value in diabetes 
and chronic nephritis. Any good form of ophthalmoscope will suffice, 
the difference being rather in the skill and cerebration of the physician 
than in any marked advantages possessed by one over another instru- 
ment. Not only is the instrument indispensable for retinoscopy and 
refraction but hardly less so for the examination of the medial and ex- 
ternal structures. 

Oblique Illumination. — A beam of light is focused obliquely 



Often the 
masterkey. 



upon lb" vu . v l surface by an indirect examination lens, which is 
held 2 t * X mencs above and to the side of the affected eye, slightly 
in front of the patient; a second lens may be used for magnification. 

Opacities oj the cornea appear as small cloudy or opaque areas {nebula) 
01 larger ones (leucomata). Deep seated opacities such as occur 
most often in syphilis yield a re/lection, superficial areas are dull. The 

presence or absence of the light reflex should be noted and the consensual 

reflex tested. Jlippus, photophobia and the pupillary contraction oj 
accommodation and convergence, are readily tested and the pupillary 
outline and its bilateral unijormity observed. The aqueous humor, 



Corneal 
opacities 



Appear- 

.moo of. 



Pupils. 



558 



MEDICAL DIAGNOSIS. 



Adhesions, 
scars and 
iritis. 



Simple 

vs. 
Specific. 



Ecchymo- 
ses and apo- 
plexy. 



Light. 



Red reflex. 

Fugitive 
reflex, and 
refraction. 



iris, lens, and vitreous may be observed if the lens is moved or the eyes 
of the patient turned as becomes necessary.* 

Iris. — The iris may show inflammation, adhesion (synechias), or the 
coloboma of a past iridectomy. Iritis. A delicate pink pericorneal 
injection maximal at the corneal margin and not moving on sliding press- 
ure upon the conjunctiva, a darkened turgid greenish iris, photophobia, 
and a sluggish, contracted, sometimes irregular pupil, indicate iritis. 

Conjunctivitis. — Shows a vivid and tortuous general hyperemia 
most marked in the cul de sac, the vessels being readily moved-by 
sliding pressure. Common in all catarrhal affections and eye-strain, 
it may in severer suppurative forms be gonorrheal, diphtheritic or 
meningeal, or, associated with pain, a symptom of corneal ulcer or even 
glaucoma. Ecchymoses occur as the result of traumatism, violent 
physical strain, asthma, epileptic seizure or in connection with haemo- 
philia, purpura, leukaemia, malignant endocarditis or pernicious anasmia. 
In several cases observed by the author an apparently causeless hemorrhage 
has preceded for weeks or months a cerebral apoplexy. 

Retinoscopy. — Sitting one metre from the patient, whose vision 
should be directed straight ahead, the source of light being slightly 
higher than the head, a beam from the perforated mirror is thrown up- 
on the pupil. The red reflex appears if the media are transparent. 
The mirror should then be tilted in all directions, the fugitive central 
reflex produced being carefully noted as it gives an exact clinical indi- 
cation of the nature of the refraction. f 

A subtraction of one diopter is always made for the one metre dis- 
tance, or a plus one spherical lens may be placed in a trial frame 
before the eye, in which case the subtraction need not be made. The 
eye must be completely under the influence of a mydriatic in doing 
retinoscopy, if accuracy is desired. 

* It is best to dilate the pupil for inspection of the l pr,c? margins and 
anterior layers of the vitreous. (Thorington.) 

f If the source of light be vertical (argand burner, not electric light) and 
the mirror concave, a straight pupillary shadow moving quickly in a direc- 
tion opposite the tilting of the mirror indicates either a normal, hyperme- 
tropic or less than one diopter myopic .eye. Movement of the shadow in 
the same direction as the mirror tilt indicates myopia exceeding one diopter 
and the higher the error the more crescentic and slow moving is the shadow. 
Astigmatism is evident if the shadow edge moves differently or with dif- 
ferent rapidity in opposed meridians. Simple astigmatism is present if 
there is movement of the shadow in only one meridian, the other being 
normal; compound astigmatism, if the movement of the shadow is similar 
in each meridian but of different degree. Mixed astigmatism is evidenced 
by different directions of the shadows in opposite meridian. 



PLATE V 




Fig. i Albuminuric Retinitis of Pregnancy 



Fig. 2. Retinitis Diabetica 




Fig. 4. Detachment of the Retina 



(From Thorington-6 "Ophthalmoscope and How to Use It "J 



DESCRIPTION OF PLATE VI. 

Fig. i — Albuminuric Retinitis of Pregnancy. Neuro-retinitis. 
Papillo -retinitis. Left Eye. Direct Method 
Fundus Changes. Disc hidden and slightly swollen. Punctate dots 
above and at the macula (neuritic dots) are conspicuous. Areas of 
exudation some distance from the disc. Hemorrhages numerous, 
small and flame-shaped. The veins full and tortuous, some are cov- 
ered by the swollen retina. 

Fig. 2. — Retinitis Diabetica. Right Eye. Direct Method. 
Fundus Changes. Arterio-sclerosis showing in the upper and lower 
temporal vessels where they cross. Small flame-shaped and round 
hemorrhages scattered irregularly in the fundus. The disc edges are 
foggy and the membrana cribrosa is indistinct. The intermediate zone 
and in fact the entire disc has a canary-yellow color appearance. 

Fig. 3. — Retinitis Pigmentosa. Right Eye. Direct Method. 

Fundus Changes. The periphery of the eye ground is characteristic 
of many myopic eyes, the choroidal vessels being very conspicuous. 
The retinal vessels are not very numerous and the smaller ones can be 
traced with difficulty in the periphery. The disc is quite yellow. The 
retinal vessels narrow. The reflex immediately around the disc 
approximates the normal, but beyond this the condition is atrophic. 
A few stellate pigment spots, together with irregular pigment massings 
on the vessels, are scattered throughout the fundus. This is an unusual 
variety of the disease. The patient is color blind for red and has 
night blindness. 

Fig. 4. — Partial Detachment of the Retina. Right Eye. 
Direct Method. 

Fundus Changes. Retina detached downward and forward. The 
wavy condition of the retina, the course of the dark-colored vessels 
without their usual light streaks, as they appear on the detachment, 
are all quite characteristic. This disc appears foggy because it is out 
of focus as compared with the detachment. The disc is seen with — 7 
D., whereas the detachment is best seen with a+ 1 D. The white 
streaks arc very likely congenital and possibly obliterated vessels. A 
rupture of the choroid would be crcseentie in shape ami situated else- 
where in the fundus. 



RETINOSCOPY. 



559 



The Fundus Oculi. — Indirect Methods of Ophthalmoscopy. Proper 
dilatation having been secured,* the patient with head slightly bent 
forward sits close to the source of light which is on a level with the ear 
lobe.f The examiner sits from i£ to 2 feet distant, the left shoulder 
advanced, a convex lens (13 diopters) in the left hand, the ophthal- 
moscope in the right. The perforated centre of the larger (concave) 
mirror should be exactly opposite the eye-hole of the instrument in 
which a + 3 diopter lens is placed. When a beam of light is thrown 
(from the mirror) upon the pupil a rosy reflex entirely fills it. The 
patient's gaze should be fixed upon the examiner's left ear if the left 
eye is under examination, upon the right little finger tip as extended 
while holding the ophthalmoscope if the right eye is under inspection. 
This reveals the optic disc, and slowly shifting the patient's gaze from 
right to left and up and down brings the periphery into view and the 
macula should be seen when the patient looks directly at the centre of 
the examiner's forehead. The large convex lens should be held between 
finger and thumb at about 2^-3 inches from the eye or at such distance 
as is indicated by its strength and the clearness of the image. It may 
be steadied by resting the little finger upon the patient's brow. J In 
indirect ophthalmoscopy the image is inverted, all relations being exactly 
reversed but the image is large and the method easy. Astigmatism is 
indicated by shrinkage or expansion of the image in any meridian attend- 
ing the slow withdrawal of the lens, and in general the contraction of 
the field upon withdrawal indicates hypermetropia; its enlargement, 
myopia, so that simple, compound, mixed or irregular astigmatism may 
be thus detected. These conditions are merely suggestive, not 
accurate. 

The Direct Method.— The advantages of this method lie in the 
magnified (cornea and crystalline lens) direct image obtained and the 
better showing of details though a smaller surface is brought into view- 
in any one position. The light should be close to the patient but behind 
and slightly above the level of the car corresponding to the eve under 
examination. The examiner must be able to slowly bring his own eve 

* A drop or two of 2% homatropine solution, or better, a fresh \% 
cocaine or cuphthalmim solution is dropped into the eye a half hour or 
more previously and followed after examination l>v a drop of eserine solu- 
tion (gr. \ to 1 o/.. of water). 

| A light directly above the head may he used for this indirect method. 

j Bed ridden patients may he examined whether recumbenl or sitting up 

!>\ propel adjustment of the light anil correct position on the part of the 

physician. 



Dilating 
pupil. 

Position of 
patient and 
examiner. 



Red reflex. 



Observing 
disc. 



Accessory 
lens. 



(lives in- 
verted 
image. 



Refractive 
errors re- 
vealed. 



Magnified 

direct 

image. 



$6o 



MEDICAL DIAGNOSIS. 



Technique. 



Relaxing 
accommo- 
dation. 



Use of 
mydriatics. 



within two inches of the one under examination and the eye used should 
correspond to the one examined (examiner's right, patient's right). 
The ophthalmoscope is applied flat to the cheek, the elbow at the side, 
the small mirror so adjusted as to give maximum reflection and the 
patient is told to look off into space over the shoulder of the examiner and 
under no circumstances to look at a near object (relaxation of accom- 
modation). The examiner must relax his own accommodation or 
if necessary use a — i D or — 2. D lens* if the patient's refraction is 
normal. The proper lens must be inserted in the ophthalmoscope 
when the patient's refractive error does not permit a distinct view of the 
retinal structures and might lead to serious misinterpretation. If the 
examiner's refraction is faulty the proper glasses should always be 
worn. As the patient must look directly in front of him to bring the 
macula into view and as the impingement of light upon that point will 
surely cause pupillary contraction, preliminary dilatation is often nec- 
essary. 

MOTOR NERVES OF THE EYE.— Motor Oculi (3rd), Patheticus 
(4th), Abducens (6th). These three nerves closely related in origin and 
course and connected by an elaborate system of association fibres 
control the movements of the eye. The yd supplies the ciliary muscle, 
levator palpebral superioris, inferior oblique and superior, inferior and 
internal recti. The 4th supplies the superior oblique, the 6th the external 
rectus. The multiple nuclei of the yd and that of the 4th lie beneath 
the floor of the Sylvian aqueduct, while that of the abducens lies lower 
beneath the floor of the 4th ventricle. 

All are much exposed to pressure in basal lesions, the yd emerging 
at the inner surfaces of the crura, the 6th between the medulla and the pons, 
while the 4th is the only nerve emerging on the dorsal surface, springing 
from the roof of the 4th ventricle immediately after it has decussated 
with its fellow. All three nerves may be affected in gumma, meningitis, 
tumor, or hemorrhage, by syphilitic or other forms of neuritis or by direct 
injur} 7 affecting the base, and one may be affected alone, the patheticus 
most rarely. Furthermore, isolated paralysis of the 4th is indicative 
of cerebellar tumor or an exudate on the anterior inferior aspect of the cere- 
bellum. As the unilateral lesions of the base usually affect cranial 
nerves of the same side with the exception of the patheticus, while pro- 
ducing hemiplegias of the opposite side, the value of crossed paralysis 



Muscles 
supplied. 



Nuclei. 



Often 
involved in 
basal 
lesions. 



Isolated 
paralysis 
of the 4th. 



* It is entirely unnecessary and wholly unwise to close one eye in using 
the ophthalmoscope and the observer should imagine that he is looking at 
a distant object. 




. 



PLATE VII 




Fig. i. Atrophy of the Optic Nerve 

{Post Papillitic Atrophy) 

A ho Meclullated Ne?ve-Jibers 



Fig. 2. Primary Optic Atrophy 




Fig. 3. Retino- Choroiditis 



Fig. 4. Glaucoma 



j 



(From Thorington-s Ophthalmoscope and How to 



Use It") 



DESCRIPTION OF PLATE VII. 

Fig. i. — Atrophy of the Optic Nerve (Post Papillitic Atrophy). 
Also Medullary Nerve -fibres. Right Eye. 
Direct Method. 
Fundus Changes. Disc is bluish, the edges not well denned, lamina 
cribrosa not present. As a coincidence there are medullary nerve-fibres 
present. The whole fundus is mottled (map-like). The retina is at- 
rophied and the macula cannot be distinguished. Arteries are straight 
and some of the larger veins slightly tortuous. 

Fig.- 2. — Primary Optic Atrophy. Right Eye. Direct Method. 
Fundus Changes. Disc bluish and glistening. Membrana cribrosa 
at centre of disc. A cilio-retinal vessel is seen on the temporal edge of 
disc passing toward the macula. Fundus reflex apparently normal. 
Vessels are not particularly narrowed at the present time. Anterio- 
sclerosis evident at crossing of vessels. Disc has "saucer" shaped 
excavation. 

Fig. 3. — Retino -choroiditis (Specific). Left Eye. Direct 

Method. 
Fundus Changes. Nasal edge of disc hidden and cannot be dis- 
tinguished from the neighboring retina. Temporal edge of disc is 
clear and reveals a narrow crescent. A few yellowish-colored spots 
seen in the choroid. Other spots of choroiditis have become absorbed 
and white areas (atrophy) have taken their places with irregular pig- 
mentations. The choroidal circulation is exposed in the periphery. 
A large patch of retino-choroiditis is seen close to the temporal side of 
the disc. 

Fig. 4. — Glaucoma. Left Eye. Direct Method. 

Fundus Changes. Edge of disc seen with + 6 D. and the bottom 
of the cup is seen with a — 5 D. Vessels of the retina disappear as 
they pass into and around the edge of the disc, and are cut of focus 
when they reach the bottom of the cup, where they appeal indistinctly 
at the nasal side. The nerve is bluish or pearly white in color and 
atrophic (glaucoma atrophy). The edges of the disc have a distinctly 
yellowish color and the pigment is broken into tine particles. There 
is a peculiar redness showing at the macula. 

The cupping embraces the entire disc. 



1 



TESTS FOR LESIONS OF THE 3RD, 4TH AND 6TH NERVES. 561 



as a localizing symptom is readily seen. Partial paralysis of motor 
oculi innervation may result from lesions involving individual nuclei or 
the roots springing from them and passing through the knee of the 
internal capsule. Complete uncomplicated unilateral paralysis of any 
motor ocular nerve indicates a lesion of its trunk and the effects of 
orbital and sinus lesions or pressure at the sphenoidal fissure should be 
held in mind. Hemiplegia of the opposite side co-existing suggests: — 
In the case of the motor oculi a midbrain lesion or a tumor involving 
pressure upon a crus in which latter case the hemiplegia precedes 
the eye involvement. // the paralyses are coincident and simultaneous 
a lesion above the corpora quadrigemina is suggested. 

Paralytic Symptoms. — Motor Oculi. Abolition of pupillary reflex 
and fixed moderate dilatation due to unopposed sympathetic influ- 
ence, the eyeball swings outward and slightly downward (unopposed 
influence of abducens and patheticus) and any attempt to overcome the 
ptosis present is accompanied by excessive contraction of the occipito- 
frontalis and a characteristic predominance of forehead wrinkles on 
the affected side.* Irritant lesions will of course cause contracted 
pupils and various ocular spasms, such as nystagmus, nictitating or 
various non-rhythmic movements, blepharospasm or hippus, may re- 
place ptosis. 

TESTS FOR LESIONS OF THE 3RD, 4TH AND 6TH 
NERVES. — These are essentially tests of pupillary activity (see page 
552) and muscular strength, the latter being best indicated by diplopia 
(double vision) inasmuch as marked impairment may exist without 
strabismus (squint). 

Strabismus.— The " cross eyed" person cannot bring the visual axis 

of both eyes simultaneously to the same point and ordinarily the defect 

is lateral, more rarely vertical. In a divergent strabismus the defective 

eye swings outward, in convergent squint inward. If the squint be 

spasmodic (concomitant) it is always made evident by asking the patient 

* Firm downward pressure over the brow by cutting off the action of the 
frontalis enables one to estimate the actual degree of ptosis. Ptosis or 
pupillary signs without other symptoms of oculo-motor involvement are not 
infrequently seen In locomotor ataxia, as in a case under the author's obser- 
vation for a long time. Ptosis may be incomplete ami is simulated by 
hysterical orbicularis spasm, a transient ptosis upon waking seen in neu- 
rotic or over-worked persons, or by paralysis oi the Mullerian fibres of the 

sympathetic in the orbital tissue, a paralysis which differs from true ptosis in 
tiie pupillary contraction and the symptoms of inflammation and edema of 

the corresponding lower lid. Furthermore, the inhibiting action of the 

association fibres of the trigeminus (5th) mav cause ptosis in trigeminal 
lesions. 



Crossed 
paralysis. 



Fixedly 

dilated 

pupil. 

Strabismus 
and ptosis. 



Irritative 
symptoms. 



Divergent 



Conver- 
gent. 



c oncomi- 
tant. 



J 



562 



MEDICAL DIAGNOSIS. 



Paralytic. 



Causes. 



Simple 
tests. 



Looking 
" toward " 
or " from ' 
the lesion. 



Effect of 
lesions. 



Taste 
affected. 



to look straight ahead, furthermore, the eye moves in any direction in 
direct ratio to the movement of the sound eye, though retaining its lack 
of parallelism, and, diplopia is usually absent. Paralytic strabismus 
on the other hand shows either total loss of movement in the affected 
muscles or marked weakness which, however may only be apparent 
when the patient looks in a certain direction or under continued fixa- 
tion of the gaze upon one object in the weak axis. The abducens is 
commonly the nerve affected. 

Diplopia. — Double vision occurs only in paralytic squint except 
when developed by special tests. It is a frequent symptom of the toxic 
irritation produced by certain drugs such as alcohol and belladonna 
or by any irritability or destructive lesion at the base of the brain. 
Having the patient follow with his eyes the finger or pencil moved 
laterally and vertically before them and their convergence as it is 
brought gradually close to his nose measures roughly the extent and 
indicates the specific muscles affected. He should be asked to tell 
the number of fingers held before him in each position, no rotation 
of the head being permitted. To find the eye and muscle producing 
double vision requires in many instances a resort to special tests * 

Conjugate Deviation. — // both eyes deviate to the same side they 
are said to "look towards" the lesion, if it be paralytic, and "away from" 
it if the condition be spasmodic {irritation) but in lesions of the pons the 
reverse is true. 

TRIFACIAL. — The 5th consists of two roots, one sensory and one 
motor. The 1st rises from a large pontine nucleus, the latter in a small 
one lying just internal to it, both being in the floor of the 4th ventricle. 
Lesions of the nerve or its nuclei produce the following symptoms: — Oph- 
thalmic Division. — Anaesthesia of the conjunctiva, skin of brow and 
nasal bridge, the upper lid, forehead and anterior portion of scalp. 

Supra-maxillary. — Anaesthesia of the alae nasi, cheeks, temples and 
nasal mucous membrane, upper pharynx, tonsils, soft palate^roof of 
mouth and upper teeth, upper lip; diminished taste and lost palate 
reflex. Inferior Maxillary. — Taste impaired in anterior portion of 

* The Candle Test. In the usual test spectacle frame of the test case 
place in front of one eye one red glass; standing several metres away move 
about a lighted candle until two images (one red, one plain) are reported 
by the patient who also states where the colored image lies with relation to 
the other. Then the colored image represents the visual axis of the cov- 
ered eye, the plain one that of the uncovered. If now by moving the 
candle in the direction of the colored image the double vision increases it 
proves the eye covered by the red glass to be affected and the weak muscle 
is that which turns the eye in the direction of the false image. 



SIXTH AND SEVENTH NERVES. 



563 



tongue, salivary flow checked; anaesthesia of the mucous membrane of 
the mouth, the lower part of the face and lower lips, trifacial neu- Neuralgis 
ralgia, paresthesia, and, as it receives the motor root, trismus or par- 
alysis of the muscles of mastication. Unless the paralysis be bilateral 
little actual disability occurs but in complete paralysis the jaw drops 
and even swallowing is difficult. Dryness of the nasal, buccal and 
conjunctival mucous membrane of course follows a lesion of the 5th 
and partial deafness may result. 

Taste. — This sense is tested by placing upon the tongue successively, 
sugar, salt, quinine and tartaric acid, the tongue being protruded 
continuously throughout the procedure and the anterior and posterior 
portions separately tested. Paresthesia (taste perversion) may be evi- 1 
dent or admitted. 

Motor Action. — The deviation of the jaw is toward a unilateral 
lesion, and when the teeth are clenched the affected muscle fails to 
contract forcibly under the palpating finger placed over the masseters. 
The perception of musical notes of different pitch tests the field of 
hearing. 

Miscellaneous Symptoms. — No sneezing follows tickling the nose, 
irritating substances do not affect the tongue or nostrils, a cup placed 
to the lips feels as if broken, the patient may support the jaw with the 
hand to aid mastication and swallowing, and atrophy and loss of reactions 
may follow the paralysis. Herpes zoster, dental decay and ulceration 
of the nasal, buccal, and corneal surfaces may occur as expressions of a 
lost trophic function. Trismus is the result of infective tetanus or 
general convulsions, a convulsive tic occasionally results from reflex 
irritation. Tonic spasm also occurs, rarely, in hysteria and after long 
continued and enforced stretching of the muscles. Clonic spasms, slow 
or fast, are seen in the fear, chill and teeth grinding so common in 
children and indicative of over-wrought nerves, worms, gastrointes- 
tinal disorders, adenoids, impacted cerumen, etc. The trifacial, while 
frequently the seat of neuralgia, is well protected from ordinary injuries 
and pressure; but may nevertheless be involved in certain bulbar palsies 
and in focal and gross lesions at the base. 

6TH NERVE. Abducens. This has the longest course of any 
cranial nerve and is frequently involved in basal lesions, producing 
internal strabismus. Its associations in disease are essentially the 
same as those of the 3d nerve. 

THE 7TH NERVE. The Facial.— An accurate oj the 

origin and connections oj the facial nerve is oj tJic utmost import: 



Trismus or 
jaw drop. 



Deafness 
perhaps. 



Substances 
used. 



Jaw- 
deviation. 



Tensor 
tympani. 



Nasal and 
labial. 



Masseters. 



Trophic 
changes. 



Spasm. 



Neuralgia. 



564 



MEDICAL DIAGNOSIS. 



Motor. 



Origin and 
course. 



Associa- 
tion. 



Cortical 
centre. 



Three 
varieties. 
Supra- 
nuclear. 

Nuclear 
and infra- 
nuclear. 



Usual type. 



Audition 
and equili 
bration. 



the clinician. It is almost purely motor and essentially the nerve of 
facial expression. The cortical fibres decussate in the raphe of the 
tegmentum and enter their nuclei at the junction of the pons and 
medulla, external to that of the 6th. 

From its origin in the pons nucleus it sweeps about the nucleus of the 
6th, which lies just external, and emerges with the 8th nerve between the 
restiform bodies and the olive at which point any lesion must include 
both nerves (7th and 8th) as they run together into the internal auditory 
meatus. In the Fallopian aqueduct it runs with its branch to the 
stapedius and the fibres of the chorda tympani and emerging at the 
junction of the mastoid and ear it passes to the facial muscle. Though 
its cortical centre lies below the motor areas of both leg and arm (in- 
ferior portion anterior frontal convolution) it lies between the two in 
the internal capsule, cms and pons. 

FACIAL SPASM AND PARALYSIS.— It is evident that a lesion 
may be either supranuclear, nuclear, or infranuclear, and that the last 
may be (a) within the aqueduct, (b) external. In supranuclear paral- 
ysis usually associated with hemiplegia the orbicularis is not affected, 
R. D. is absent and the paralysis is on the same side as that of the 
leg or arm muscles, save in lower pontine lesions. Nuclear paralysis 
is essentially that of the infranuclear type, but seldom exists alone. 
A lesion within the aqueduct involves the chorda tympani and the 
stapedius branch, hence there is loss of taste over the anterior § of 
the tongue, and often hyperacusis (exaggerated sound sensation). A 
lesion involving the nerve at its point of emergence involves the auditory, 
hence is associated with the various symptoms of irritation or paralysis 
of that nerve. If the fibres are involved between the nuclei and their 
decussation (lower pontine lesions) crossed paralysis results. 

General irritative symptoms may be present, muscle spasm, blepharo- 
spasm and convulsive tic, symptomless paralysis of such muscles as the 
stylohyoid, or characteristic paralysis of the muscles of expression in which 
case facial expression lines are obliterated and the victim cannot whistle, 
draw the corners of the mouth outward, close the watering eyes tightly 
or wrinkle the forehead of the affected side. Bilateral palsy is rare as 
an independent lesion. Monoplegia is the type and in haemiplegia 
with alternating facial paralysis we deal with the nuclear form. 

AUDITORY NERVE.— The dorsal root contains the auditory fibres, 
the ventral those of equilibration and passing out on either side of the 
restiform body they join and within the internal meatus pass to the 
cochlea for audition and to the vestibule and semicircular canal for 



, 



AUDITORY NERVE. 



565 



equilibration. The cortical centre for hearing lies in the opposite 
temporal lobe, that of equilibrium in the cerebellum. 

Symptoms. — Deafness and paresthesia if the cochlea only be involved. 
Vertigo, vomiting, tinnitus auriuni, sibilant or roaring sounds ("escaping 
steam") associated with disturbance of equilibrium if the labyrinth 
branch be affected (Meniere's syndrome). That common and ordi- 
narily trivial symptom, tinnitus aurium, like deafness, may be due to 
many causes, such as catarrh of the middle ear and Eustachian tube, 
or neurasthenia (the common causes), anaemia, digestive disorders and 
various toxaemias, inflammation or impacted cerumen in the external 
meatus, tympanites, meningitis, syphilis, brain tumor, full doses of 
salicylate, quinine, etc. Tinnitus cerebri, i.e., the sound seeming to 
arise in the brain itself, is frequent in arterio-sclerosis and is also 
found in meningeal cases. 

Deafness. — "Nervous deafness," i.e., that arising from cortical, 
nuclear, or peripheral nerve lesions is rare; that due to catarrh of the 
middle ear and impacted cerumen common. Hearing is ordinarily tested 
by the watch, which should be held at varying distances from the ear 
and the range of the patient compared with the known normal for 
the particular watch used. If deafness is evident the tuning fork should 
be employed to test by bone conduction the integrity of the cochlear nerve 
and centres. If the vibrating fork or watch is best heard when placed 
directly upon the mastoid the nerve is not at fault.* In most instances 
sudden deafness is due to impacted cerumen, hysteria, or syphilis of 
the internal ear. Naso-pharyngeal catarrh, usually associated with 
Eustachian involvement, adenoids and polypi must be remembered 
as well as growths and swellings in the auditory meatus. In head- 
ache, mental strain or fatigue, or pronounced mental irritability, sounds 
may be exaggerated (hyperacusis) or actually painful. In hysteria, 
decided or complete deafness may come on suddenly, is manifested 
chiefly in defective range for notes of varying pitch, and shows rela- 
tively equal loss of both aerial and bone conduction. It may suddenly 
disappear and usually follows emotional shock. 

Meniere's Disease.— This combines progressive nervous deafness 

with paroxysmal attacks of vertigo, forced movements, tinnitus aurium 

and a peculiar inco-ordination of the eye and head muscles. Nausea. 

* Rhino's tost: — Set tuning fork in vibration, plate handle against mas 

toid or zygoma, dosing meatus at same time. When it becomes inaudible, 
open the meatus and hold tin- still vibrating fork to it. Normally the 
soundjshould still bo heard at the meatus; abnormally bone conduction is 
the greater. 

37 



Cortical 
centres. 



Cochlea. 



Meniere's 
syndrome. 
Tinnitus 
aurium. 



Nervous 
form rare. 



Tests. 



Sudden 
deafness. 



Ordinary 
form. 



1 [ypera- 

cusis, 

Hysteria. 



566 



MEDICAL DIAGNOSIS. 



Word 
deafness. 



Deaf 

mutism. 



Transient 
deafness. 



Seldom 

paralyzed 

alone. 



vomiting and even transient unconsciousness may accompany the 
attacks. 

Cortical Lesions. — Though rarely bilateral, cortical lesions may be 
present and a lesion of the left cortical centre may cause word deafness, 
i.e. inability to interpret the sounds heard. Tumor, hemorrhage, 
meningitis, abscess, and syphilis may involve the internal capsule or 
corpora quadrigemina. The nerve itself may be injured or compressed 
by tumors and inflammatory or hemorrhagic exudates, or be involved 
in diphtheritic paralysis, locomotor ataxia, and traumatism. Deaf 
mutism is not an unusual sequence of cerebro-spinal meningitis. Laby- 
rinthine disease is usually a primary disease of the labyrinth or secondary 
to middle ear suppuration and necrosis and mastoid disease. Certain 
forms of, usually transient, deafness follow the administration of qui- 
nine and the salicylates, violent concussion or constant and repeated 
1 ^er sounds (occupational deafness). 

. GLOSSO-PHARYNGEAL NERVE.— The 9 th nerve is seldom par- 
alyzed alone and a lesion is recognized only through its sensory dis- 
turbances, though it is motor for the stylo-pharyngeus and middle 
pharyngeal constrictors. The sensory fibres run to the brain with 
the 5th nerve and a loss of taste over the posterior surface of the 
tongue, and of the pharyngeal reflex are the only sources of infor- 
mation. Root involvement does not affect taste on account of the 
peculiar course of the sensor} 7 fibres. 

THE VAGUS. — The 10th nerve has most interesting and compli- 
cated functions. It is motor for the pharynx, larynx and soft palate and 
both motor and sensory for the heart, respiratory passages and most of 
the abdominal viscera, in connection with which the sympathetic plays 
an important part. Its motor fibres, including the cardio-inhibitory 
group, are contained in what was formerly regarded as the bulbar 
porton of the spinal accessory which joins it outside the cranium. The 
pharyngeal plexus is formed by the vagus and glosso -pharyngeal nerves 
and supplies the pharyngeal muscles and mucosa, hence a lesion of 
the nuclei or trunks gives rise to marked dysphagia. 

Tests. — Complete paralysis of the palate is indicated by regurgita- 
tion of fluids through the nose in swallowing and thick nasal speech. 
If the palate be examined while the patient says "eh" and "ah", 
defective upward movement is perceived; if unilateral, immobility of one 
side with dragging of the median raphe towards the sound side. 

The Laryngeal Nerves. — The superior and inferior laryngeal 
nerves supply the musculature and mucosa of the larynx. The recur- 



A marvel- 
ous nerve. 



Spinal 

accessory 

association. 



Dysphagia. 



Palatal 
paralysis. 



Laryngeal 
supply. 



SPINAL ACCESSORY. 



567 



rent laryngeal which supplies the mucosa of the lower portion and all 
muscles except the crico thyroid, is especially liable to pressure par- 
alysis by reason of its relation to mediastinal structures, aneurism 
being one of the commoner causes of paralysis of the left recurrent. 
Bilateral paralysis of the abductors causes imperfect approximation and 
separation of the vocal cords in respiration and voice production. 
The symptoms are inspiratory stridor without aphonia, the cords being 
nearly approximated. It is encountered in cases of hysteria and occa- 
sionally follows a simple laryngitis though usually toxic. Pressure 
upon one recurrent nerve, usually aneurismal or due to pleural 
adhesion, produces unilateral abductor paralysis, immobility of the 
affected cord in inspiration and hoarseness. Adductor paralysis is 
usually hysterical and the separation of the cords produces aphonia. 
(See fig. 217.) 

Laryngeal Spasm. — The croup of children, locomotor ataxia (laryn- 
geal crisis) and hysteria are the commonest sources, the last form being 
chronic and usually associated with speech production. 

Anaesthesia. — Due to diphtheria, neuritis, bulbar paralysis, or 
hysteria, makes feeding difficult and inhalation pneumonia common. 
Hyperaesthesia is rare, but occasionally seen, especially in sexual neu- 
rasthenia. 

Cardiac Plexus. — Formed by the vagi and sympathetic nerves 
its branches control the activity of the heart. Stimulation of the vagus 
slows or temporarily arrests the heart action, and in rare instances 
voluntary inhibition has been observed. In complete paralysis the 
accelerator fibres act unhindered causing rapid heart action. Palpi- 
tation and cardiac pain are probably appreciated through the vagus path. 

Gastric Branches. — The vagi control the activity of both stomach 
and esophagus, conveying sensory impressions as well as motor 
stimuli and are probably concerned with so-called nervous dyspepsia 
and the gastric crises of locomotor ataxia. In bulbar paralysis the 
nuclei of the accessory nerve and the hypo-glossal are involved with 
those of the vagus. 

SPINAL ACCESSORY. -The chief function of the nth nerve is 
the supply of the sterno mastoid and trapezius muscles, and. through 
,the vagus, the pharynx and larynx. 

Tests. The laryngeal paralyses have already been covered. Paral- 
ysis of the sterno mastoid prevents wholly or in part rotation o\ the 
chin towards the sound side, and if the trapezius be paralyzed, shrug- 
ging oi the shoulders is interfered with. (See also \\ 546.) 



Chiefly 

recurrent 

branch. 



Common 
types. 



Dangers. 



As affect- 
ing heart 
action. 



Bulbar 
paralj si: 



sterno 
mastoid 
and tra- 



568 



MEDICAL DIAGNOSIS. 



Cortical 

vs. 
Peripheral 
palsy. 



Chiefly in 
the insane, 
alcholic 
and aged. 



Three 
forms. 



HYPOGLOSSAL NERVE.— The 12th is entirely motor and sup- 
plies the tongue and depressors of the hyoid bone. It rises from a 
nucleus nearly median in the lower portion of the floor of the 4th 
ventricle and its cortical centre lies in the lower frontal convolution. 

Tests. — Note evidence of wasting and tremor or fibrillary contraction. 
Wasting indicates a nuclear or trunk lesion, its absence a supra -nuclear 
or cortical lesion. Deflection of the tongue towards the paralyzed side 
is evident on protrusion. (See also p. 544.) 

THE SYMPATHETIC NERVOUS SYSTEM.— The anterior 
horns of the cord carry fibres of unknown cortical origin to the sym- 
pathetic ganglia through a special set of axones running in the ante- 
rior nerve roots, and sympathetic ganglion cells with their axones in turn 
constitute the motor sympathetic neurone. A similar set of fibres (sen- 
sory') traverse the posterior roots and there is a free communication 
between the cranial nerves and the sympathetic system. The vaso- 
motor fibres are especially plentiful in the anterior roots of the dorsal 
region. The visceral fibres are chiefly in the cervical region where 
they accompany the accessory and vagus nerves and ultimately pass 
to the alimentary canal. 

The wonderful automatic control exercised by these nerves cannot 
be dealt with here but though their activity may continue when all 
central nervous connections are cut, they are to a certain extent controlled 
and regulated by the higher centres, The cilio-spinal fibres are impor- 
tant in diagnosis, irritation causing pupillary dilatation; section, contrac- 
tion. Other symptoms .of sympathetic origin are: — vaso-motor spasm 
or relaxation, abnormal sweating in the involved areas and various 
disturbances of glandular secretion and cardiac and visceral activity. 

DISEASES OF THE BRAIN AND SPINAL CORD. 

HEMORRHAGIC PACHYMENINGITIS {internal meningeal 
hematoma). — This may be encountered in either the brain or the cord. 
The cerebral form is almost exclusively confined to the insane (especially 
paralytic dementia) and the aged, though occasionally met with in vas- 
cular degeneration, profound anaemias, alcoholisms, cachexias, diseases 
of the purpuric type and even in acute infections. Pathologically 
three forms may be seen, (a), simple subdural hemorrhagic exudate, 
(b) an inflammatory exudate converted into a delicate vascular membrane 
by granular tissue and vascular extension, (c) the two conditions combined. 
In the insane and aged it is supposed that the cerebral atrophy so fre- 
quently encountered is a contributive factor. 



DISEASES OF THE BRAIN AND SPINAL CORD. 



569 



Symptoms. — If any exist they are those of intracranial pressure, 
recurrent convulsions, coma and paralyses. 

SPINAL FORM. — This may involve any portion of the dura mater 
of the cord (most commonly the cervical enlargement) or even be 
accompanied by cerebral hematoma. Pressure symptoms occur accom- 
panied by secondary degeneration and producing intense peripheral 
neuralgic pain chiefly brachial and cervical with hyperesthesia and 
paresthesia, slowly progressive muscular weakness, paralysis and 
muscle atrophy. Prognosis. — The disease is chronic, usually fatal 
within two years, and during the later months is often associated 
with spastic paraplegia of the lower extremities. 

Differential Diagnosis. — It cannot be distinguished from tumors 
of the cord. Amyotrophic lateral sclerosis lacks the severer neuralgic 
pain, and syringomyelia may be differentiated by its characteristic 
sensory symptoms. See p. 600. Pseudo-membranous and purulent 
pachymeningitis are not worthy of detailed consideration. 

EXTERNAL PACHYMENINGITIS.— Both the cerebral and 
spinal forms yield the symptoms of compression and ordinarily result 
from traumatism, caries or the extension of some suppurative process. 
It is most frequently secondary to syphilis and tuberculosis, tumors 
or suppuration, involving the adjacent structures. 

Extra-meningeal Hemorrhage. — Aneurismal rupture or trauma- 
tism involving the peridural plexus may cause hemorrhage usually 
with pressure symptoms. Intra-meningeal Hemorrhage is more 
often a complication of acute febrile toxemia, convulsive seizures and 
the rupture of basilar vertebral aneurisms, less often traumatism. 

Symptoms. — These are usually localized pressure symptoms of 
sudden development, and cases secondary to acute febrile toxemia 
and traumatism furnish the most favorable prognosis. 

Haematomyelia. — Hemorrhage into the cord itself, usually associated 
with heematorrhachis may result from the causes of intra-meningeal 
hemorrhage, but is more often due to direct injury and is undoubtedly 
one oj the causes oj the disturbances noted after injuries involving violent 
flexion or torsion oj the spine. The hemorrhage varies greatly in extent 
and position and the paralysis may be paraplegic or unequally affect 
the two sides, but is frequently unilateral producing the well known 
Brown-Sequard symptom complex, viz.: unilateral motor paralysis 

with anaesthesia of the opposite side, etc. i^See p. 526.) Tain Is usually 

slight or absent; paresthesias are common and the lumbar or eervieal 

regions are most frequently affected. The onset is sudden, and in 



Pressure 
symptom! 



Chronic 
course. 



H;emator- 
rhachis. 



Usually di- 
rectly fol- 
low s injury, 



Sudden on- 
set \ alua- 

ble s.*;n. 



57o 



MEDICAL DIAGNOSIS. 



Decom- 
pression 
the factor. 



Symptoms 
variable. 



Transient. 



Unim- 
portant. 



Male adults 
chiefly. 



Whole tract 
involved. 



Character- 
istic com- 
plex. 



low seated lesions urinary retention or incontinence is often 
observed. 

Prognosis. — Partial recovery is the rule and fatal termination the 
exception, both primary and residual paralyses are chiefly of the 
spastic type. 

CAISSON DISEASE.— This obscure ailment is encountered in 
submarine workers exposed to high grades of atmospheric pressure and 
seems to be connected with the sudden relief of such pressure. The 
changes seem to be strictly limited to the cord, taking the form of 
punctate hemorrhage, myelitis or laceration. There is an unproven 
theory that it is due to the release of nitrogen taken up by the blood 
under high pressure. 

Symptoms. — Immediately after leaving the caisson or perhaps not 
for 48 or 72 hours a series of symptoms develop varying in severity 
from excruciating pain in the lower extremities to spastic paraplegia 
with anaesthesia and urinary retention. Coma is sometimes observed, but 
the upper extremities are seldom affected and many minor symptoms 
such as temporary albuminuria, vertigo, deafness and tinnitus aurium 
may be encountered. The disease is rarely fatal and the symptoms 
ordinarily disappear in a few days or weeks. 

"MILIARY" ("diffuse", "tuberous") SCLEROSIS may be 
dismissed as of little practical importance, all three varieties being 
associated with mental disease and seldom encountered save in the 
autopsy rooms of asylums. 

MULTIPLE SCLEROSIS ("insular," "disseminated") is a dis- 
ease of unknown causation occurring chiefly in young male adults and 
characterized anatomically by an extensive irregular dissemination of 
reddish gray areas of sclerosis involving both the gray and white sub- 
stance of all portions of the cerebro-spinal tract. The cerebral lesions 
ordinarily predominate and in the cord the cervical region and the 
cauda equina are usually chiefly affected. In the former the brain 
stem and basal ganglia suffer most. 

Diagnosis. — Intention tremor, lessened in recumbency, nystagmus, scan- 
ning speech and transient palsies are the important symptoms. Vertigo, 
optic atrophy, spastic weakness of the lower extremities and stiff awk- 
ward gait is common, enfeebled mentality and sudden attacks of coma 
may occur and the symptoms may be extraordinarily varied and slow and 
insidious in development. The sphincters may be affected in the term- 
inal stage. Differential points. Paralysis agitans lacks nystagmus 
and shows tremor during rest. Hysteria lacks nystagmus and pre- 



DISEASES OF THE BRAIN AND SPINAL CORD. 



571 



sents usually distinctive stigmata. Prognosis. — It is markedly chronic 
and terminates by intercurrent disease, usually after the patient has 
become bed-ridden. 

CEREBRAL CONGESTION.— Cerebral congestion has lost its 
place as an important clinical entity, most of the symptoms formerly 
classed under that head being due to toxaemia rather than mere congestion 
and to be referred to some underlying disease to which congestion is 
purely secondary. Mental excitement, indeed any mental effort means 
temporary congestion and certain drugs such as alcohol, quinine and 
strychnia undoubtedly produce it. Passive hyperemia must occur in 
certain obstructive conditions affecting the circulations, either of the 
brain itself, or of the body generally, as is seen in cardiac weakness 
of extreme degree from any cause. The symptoms are headache of 
varying degree, often associated with a subjective sensation of pressure 
and pulsation, vertigo, tinnitus aurium, mental irritability and impaired 
concentration. 

CEREBRAL ANEMIA.— Cerebral anaemia may be (a) simply 
a part of general anaemia; (b) due to temporary vaso-motor changes; 
(c) the actual loss of blood, or (d) arterio-sclerosis. Nausea, vertigo, 
faintness or actual syncope are the symptoms of the first three groups; 
mental depression, impaired concentration, drowsiness during the day and 
particularly after meals, frequent headache and insomnia the chief symp- 
toms of the last group, but there is no sharp line of division. The 
headaches associated with marked general anaemia are usually dull but 
may assume a very violent type. The insomnia usually comes on after 
a period of sleep, the patient lying awake the balance of the night or 
merely catching short naps. 

CEREBRAL EDEMA.— This condition is chiefly of interest in con- 
nection with the uraemia of Bright's disease, the unilateral paralysis 
or spasm sometimes observed therein being probably due to a localized 
cerebral edema. Congestive edema may be a part of extreme venous 
congestion or a local congestion due to obstruction, cerebral growths or 
abscesses. 

THROMBOSIS OF THE CEREBRAL VEINS AND 
SINUSES. — This Condition is extremely rare as a primary lesion but 
much more common as a secondary event in other diseases. The 
existence of such a primary disease as suppurative otitis media. aSSOCi 
ated pulmonary infarct and marked cerebral symptoms resembling 
abscess, are the chief factors in diagnosis. 

MENINGITIS. Inasmuch as the characteristic symptoms of menin- 



Marked 

chronicity. 



Reduced in 
importance 



Familiar 
symptoms. 



.Symptoms 
common to 
all types. 



Insomnia. 



Presump- 
tive only. 



AnU 
tern. 



Permits 

tontattv 
i 



572 



MEDICAL DIAGNOSIS. 



A lepto- 
meningitis. 



Five 

varieties. 



Young 
children 
most af- 
fected. 



(i). In- 
volves both 
brain and 
cord. 

(5). Chiefly 
the con- 
vexity. 



(3 and 4). 

Base 

chiefly. 



(1). Morbid 
anatomy. 



(5). Morbid 
anatomy. 



gitis are very similar in all its acute forms these will be considered 
under one head. The lesion is in every case essentially an inflam- 
mation of the pia mater, localized or general, and shows a predilec- 
tion for certain regions in its different forms. We distinguish (1). 
Epidemic cerebrospinal meningitis due to the meningococcus of Weich- 
selbaum. (2). The simple or sporadic form which is probably due to 
the same germ. (3). Tuberculous meningitis due to direct tuberculous 
invasion and associated in 80% of all cases with a pre-existing tubercu- 
lar focus in other portions of the body which may only be evident upon 
a painstaking postmortem investigation. (4). Syphilitic meningitis. 
(5). Secondary meningitis due to septic infection or the toxins of 
acute infectious diseases. With the exception of the syphilitic and 
secondary forms the disease shows a special tendency to develop in 
infancy and early childhood. 

Morbid Anatomy. — In the epidemic form the entire pia mater of 
both brain and spinal cord is involved but to the ordinary symptoms of 
meningeal inflammation are added those indicative of an acute febrile 
toxaemia. In the septic and secondary forms, the pia of the convexity 
is chiefly affected often in limited areas and the base may entirely escape, 
this being especially true of cases due to direct injury or extension of 
disease from the mastoid cells or nasal structures. In tuberculous menin- 
gitis the involvement is so often limited to the base as to give it the name 
of "basilar meningitis," though it would seem that syphilitic meningitis 
was quite as well entitled to the term. 

In cerebrospinal meningitis the general inflammation of the meninges 
of the brain and cord is associated with an exudation of serum, fibrin 
and pus, most abundant at the base of the brain and posterior surface 
of the cord though in malignant rapidly fatal cases nothing may be 
found but an intense acute congestion. In those of long duration there is 
thickening of the meninges and yellow areas mark the seat of past 
exudation. The ventricles contain turbid fluid, and in chronic cases, 
may be greatly distended. Foci of purulent infiltration and of hemor- 
rhage may be found, and cranial and spinal nerves are of course envel- 
oped by the exudate which constantly contains the diplococcus* In 
some cases the central canal is dilated. In purulent meningitis there is 
a tendency to the formation of multiple abscesses and the exudate will 

* This germ described by Weichselbaum in 1887 is aerobic, non- 
motile, occurs in pairs, fours or short chains and unlike the pneumonococ- 
cus does not grow on gelatine but on blood serum, and shows small cir- 
cular smooth colonies. 



SYMPTOMS OF THE VARIOUS TYPES OF MENINGITIS. 



573 



yield cultures of the associated germs. It is said that actinomycosis is 
indicated by yellowish granules, pyogenic cocci by a cohesive exudate, 
and that it is thick and yellow in tuberculosis. In chronic inflammation 
of the pia there is an increase in connective tissue producing linear 
surface projections and a marked tendency to adhesions. By com- 
pression cerebral nerves may be destroyed, ventricular openings oblit- 
erated and hydrocephalus produced. Tuberculous Meningitis. The ( 
development of miliary tubercles is superadded to an inflammation with 
sero-fibrinous or more commonly purulent ex- 
udate. The tiny gray points appear chiefly in 
the choroid plexus, along the Sylvian artery, 
inner surface of the dura, membranes of the 
cord, and even the retina. The usual changes, 
i.e., hyaline and caseous degeneration, occur and 
tubercle bacilli are ordinarily readily found. 



anatomy. 




Syphilis is indicated by the presence of soft (4). Morbid 
grayish red areas, most common at the base, 



Fig. 225. — Diplococcus 
intracellularis meningiti- 
dis. (Weichselbaum.) In 

actual specimens the tending to undergo caseous degeneration, absorp- 

germs are (like the gono- ° ° ° 

coccus) chiefly within the tion and cicatrici?l contraction. 

polynuclear leucocytes. 

and the cortex may be involved 



anatomy 



Both the dura 
Hydrocephalus Hydro- 
results from an arrest of the flow of the cerebro-spinal fluid secreted cepha 
by the choroid plexuses of the lateral ventricles by blocking, com- 
pression or adhesion, of the aqueduct of Sylvius or the foramen of 
Monro. In many cases of tuberculosis and practically all cases of 
syphilis the exudate is non-purulent. 

SYMPTOMS OF THE VARIOUS TYPES OF MENINGITIS. 

EPIDEMIC CEREBRO-SPINAL MENINGITIS. -(Petechial 

fever, spotted fever, malignant purpuric fever.) The incubation period 
is undetermined, the onset usually sudden, though headache, anorexia 
and pain in the back may precede it. There are chill, causeless pro- 
jectile or regurgitant vomiting, headache, severe backache, painful cervical 
and dorsal rigidity and usually moderate fever (ioi°-io2° F.). Auditory 
and visual hyperesthesia co-exists with restlessness, irritability and muscu- 
lar tremor. The head is retracted (boring occiput), opisthotonos or more 
commonly orthotonos may occur and in children, general convulsions. 
Facial spasm, strabismus and ptosis are common ami pain in the head, 
back and extremities increases, and less frequently the trunk muscles 
may be paralyzed. Spinal or general hypcrusthesia is often noted 
and marked irritability may give place to delirium, stupor and finally 



Irritative 
symptoms 



s 



A 



574 



MEDICAL DIAGNOSIS. 



Urine. 
Fever. 



Pulse and 
respiration. 



Blood. 

Constipa- 
tion. 

Skin 
rashes. 



Errors 
common. 



Convales- 
cence 
tedious. 



Residual 
lesions. 



Chief 
features. 

Tubercu- 
lous form 
less abrupt. 



coma. Albumen, sugar, and in malignant cases blood may be present 
in the urine. The fever curve is extremely variable, some cases showing 
hyperpyrexia, others almost no fever. Respiration is not markedly 
increased but the pulse is sometimes remarkably slowed and almost 
always weak, but in children may be much accelerated. Leucocytosis 
is present in all cases (20,000 to 40,000).* The bowels are usually 
constipated, the spleen moderately enlarged, excessive vomiting is an 
unusual but troublesome complication. The cutaneous symptoms 
vary greatly, herpes is almost constant, purpuric spots occur in from 
two-thirds to three-fourths of the cases. Dusky mottling, erythema, 
rose spots, urticaria and various other eruptions may be present. 

Malignant cases may kill so promptly that the brain shows at 
autopsy only an acute congestion, they are often apyretic and are almost 
invariably associated with purpuric rash and feeble pulse, somnolence 
and pronounced gesthenia. Intermittent Form.— This is characterized 
by a febrile curve of a distinctly pyaemic type. A chronic form may 
succeed the acute. Abortive Form. — This somewhat doubtful type 
I is characterized by a severe onset, an extremely short duration and a 
sudden termination, followed by rapid convalescence. Certain other 
mild types present symptoms hardly more than suggestive which 
promptly subside and in each of these varieties there is abundant op- 
portunity for erroneous conclusions. 

Complications. — These are, chiefly, pneumonia, often of a true 
meningococcus type, septic arthritis, peri- and endo-carditis and paro- 
titis. Convalescence may be greatly prolonged and complicated by 
persistence of headache, nervous irritability or even mental impairment, 
or long persisting cranial nerve paralysis. Optic neuritis occasionally 
occurs as does parotitis, purulent conjunctivitis, choroiditis and iritis. 
Permanent deafness and persistent ocular palsies are very common and 
the frequency of nasal catarrh suggests the nasal secretion as a possible 
chief vehicle of infection. 

Diagnosis. — The presence of an epidemic, and the characteristic 
symptoms of cerebrospinal irritation and compression ordinarily make 
the diagnosis easy, yet the cerebral symptoms present in other acute 
febrile conditions are often misleading. Tuberculous meningitis 
usually lacks the sudden onset and rapid development. The rash, 
if present, is of great assistance; herpes, leucocytosis and diminished 
urinary chlorides assist in the differentiation from typhoid; the physical 

* Leucocytosis is also present in tuberculous cases though not so con- 
stantly. 




Fig. 226.— Kernig's sign. 
Proper method, i. e. pre- 
liminary flexion of thighs 
on abdomen followed by at- 
tempted extension of leg 
on thigh. 



SYMPTOMS OF THE VARIOUS TYPES OF MENINGITIS. 575 

signs from pneumonia, though either disease may co-exist with meningitis. 
The two most valuable and important symptoms oj meningitis are 
Kernig's sign and lumbar puncture. 

Kernig's Sign. — Flex the thigh at right angles to the abdomen, the 
leg upon the thigh; if meningitis is present, 
extension of the leg is then prevented by con- 
traction of the hamstrings. This sign is present 
in 90% of the cases, but is also to be found in 
sciatica, diseases of the hip and knee joint and 
lesions of the cerebellum or upper motor neu- 
rones and to a less degree in old age or after 
prolonged fixed recumbency. 

Lumbar Puncture. — Place the patient on 
the side, the body so bent as to get the max- 
imum dorsal curve, carefully count the vertebrae 
and introduce the sterile needle of an aspirating 
syringe slightly to one side of the median line 
between the 2nd and yd or yd and 4th lumbar 
verlebrce* the needle point being directed towards 
the centre of the canal. In children, a point midway between two 
spinous processes should be chosen, in adults it should pass just below 
the lower margin of the upper process of the chosen space. A long needle 
is needed, the distance traversed varying from 
2 cm. in children to from 4-6 cm. in the adult. 
Pressure is indicated by the force of the flow 
and normally represents 5-7 mm. of mercury, 
which may be increased to from 15-60 mm. 
in meningitis and tumors (Sahli). It is easily 
measured by attaching a small (1 mm. calibre) 
mercury manometer. Normally the fluid is 
clear and limpid, sp. gr.-ioo3, and but slightly 
albuminous. Marked cloudiness and the pres- 
ence of leucocytes points to septic meningitis, 
the fluid being relatively clear in tuberculous 
meningitis and cerebral abscess. High albumin 
content is also significant though occasionally en- 
countered in tumor and apoplexy. A smear should be made ami stained 
for the specific diploCOCCUS alter eentrifugali/.ation. i^See also \\ 573.) 



Two best 

si^ns. 



Exact pro- 
cedure 
necessary. 

Present in 
other con- 
ditions. 




Technique. 



Point of 
election. 



Children 

vs. 

Adults. 



Depth of 
puncture. 

Pressure 

indications. 



Fig. 227.— Kernig s sign, 
mproper method lacking 



tin- e 
Hexioi 

dome 

IUT. I 



ential preliminarj 
oi thighs upon ab 

I Alter S.ddi \\ u- 



Cyto-dia*- 

■ s - 






*To avoid the spinal cord Sahli p 

lumbar and tin* sacrum. 



tiers tin* interval between the 5th 



576 



MEDICAL DIAGNOSIS. 



Pre-exist- 
ing disease. 



Prodro- 

mata 

marked. 

ist Stage. 



2d Stage. 



3d Stage. 



Typhoid 
state. 



Duration. 



Symptom 
diversity a 
feature of 
meningitis. 



Ophthalmo- 
plegia. 



Brain 
tumor 
symptoms. 



Prognosis. — Over 50% of the deaths occur in the first week and the 
mortality ranges from 20 to 80%, being higher in children than in 
adults. Hyperpyrexia, coma, repeated convulsions and sudden fall 
of fever are unfavorable signs. 

ACUTE TUBERCULOUS MENINGITIS.— The symptoms of this 
ailment are in general exactly the same as in other forms 0) meningitis, but 
as assisting differential diagnosis, there is frequently a history of pre-existing 
tuberculosis in other parts of the body, or the disease may be a part of an 
acute miliary process. Furthermore, there are usually marked prodromal 
symptoms such as general failure of health extending over several weeks, 
loss of weight and appetite, irritability, headache and restlessness. The 
actual onset may be somewhat abrupt in children and there is the curi- 
ous whining hydrocephalic cry,* apparently due to exacerbation of the 
headache. The pulse, at first rapid, becomes slow, and irregular, the 
respirations irregular and sighing and the pupils are generally contracted 
(stage of irritation). In the second stage there is obstinate constipation, 
marked emaciation, retraction of the abdomen (scaphoid belly), boring 
occiput, stupor and irregular or dilated pupils, often associated with 
strabismus. The temperature is usually moderate in both stages (101 
-103 F) . The third stage (paralysis, coma) : — Paralysis of the ocular mus- 
cles is common, optic neuritis may be present, diarrhoea may replace con- 
stipation, and the victim lies with partially open eyes and dilated pupils, 
in a typhoid state. Temperature may at this stage be subnormal, the 
pulse rapid, and there may be antemortem hyperpyrexia. The duration 
varies from a few days to a month, from two to three weeks being the 
common period. Occasionally instances of a chronic course are encount- 
ered some of which lack the pronounced initial symptoms. 

General Comment. — The greatest diversity of symptomatology 
must be expected in a lesion involving the brain stem and perhaps the 
cortex in an inflammation associated with the outpouring of an exudate. 
The pupillary symptoms are quite constant as regards miosis of the early 
stage and the irregularity and dilatation of the later periods. Projectile 
vomiting and convulsive seizures or even tetanic contractions or catalepsy 
may be encountered in the earlier periods, and ocular palsies may exist 
alone or be associated with extensive cranial involvement. 

Prognosis. — Practically all cases die. 

SYPHILITIC MENINGITIS.— The symptoms are those of brain 
tumor, headache being pronounced and usually increased at night, and 
irritability, change in disposition and lack of appetite are prominent 
* Occasionally screaming is marked and almost constant. 



SYMPTOMS OF THE VARIOUS TYPES OF MENINGITIS. 577 

features. Causeless vomiting and vertigo may be present and eye symp- 
toms or facial paralysis may indicate involvement of the cranial nerves. 
Cerebellar ataxia and polyuria may occur and if the Sylvian fissure Wide ranee 
be involved there may be hemiplegia or aphasia. To name all of the toms" 1 ^ 
symptoms would be to review the whole subject of brain symptoma- 
tology. The essential feature is the distinctly slow onset and the ready Slow onset 
response of this condition to treatment, the diagnosis being usually peuticlest 
assisted by a history of syphilis or visible evidence of previous infection. ' 
Without antisyphilitic treatment the diagnosis between syphilitic dis- 
ease and brain tumor can hardly be made. 

ALCOHOLIC MENINGITIS.— The form of meningitis known as 
wet brain deserves special mention because of its frequent occurrence in History of 
alcoholics and certain peculiarities in its course and symptomatology. 
It usually terminates a long debauch and is frequently a terminal event 
in delirium tremens. Its characteristics are stupor or coma with low Halluci- 
muttering delirium, hallucinations and delusions. There is a general marked. 
muscular tenderness, cutaneous hyperesthesia, contraction of the pupils, Occupation 
and after a short time muscular rigidity, occipital retraction, loss of Suggestive. 
control of the sphincters, exaggerated reflexes and scaphoid belly. The 
temperature is variable, often being normal or slightly raised throughout j 
the disease, occasionally higher, especially at the close. The final 
stage may never be reached, the case terminating in recovery. The 
diagnosis is based largely upon the peculiar delirium and the history 
of alcoholism and is sometimes assisted by a knowledge of the occupa- 
tion. 

SECONDARY AND SEPTIC MENINGITIS, These cases pre- 
sent merely the symptoms of meningitis as already described, usually in 
the presence of a suggestive antecedent acute or chronic disease, or the 
history of traumatism, accidental or operative. In acute diseases error is Primary 
likely to occur from two sources, one, the fact that certain acute febrile suggests 
ailments such as pneumonia may present marked meningeal symptoms 
without true meningitis, the other, the liability that true meningeal 

symptoms may be masked by those of the disease which it compli- 
cates. These difficulties apply Of Course only to the stage oi irritation lumbar 
and the doubtful diagnosis may almost always be made certain by doubtful 

Lumbar puncture. 
INFANTILE MENINGITIS. A word is necessary concerning the 

special symptoms present in cases of simple meningitis affecting babes. 
The period of maximum susceptibility seems to lie between the third and 
sixth month. t'he symptoms are usually sudden in onset, and frank 



c.\>c- 



578 



MEDICAL DIAGNOSIS. 



Suggests 
cerebro- 
spinal 
fever. 



Pressure 
symptoms. 



Course and 

termina- 



Statistical 
data. 



in their character, pain in the early stage being indicated by pulling the 
hair and constant crying or screaming. Emaciation is peculiarly rapid, 
and hydrocephalus is usually evident by the second week, the head 
enlarging and assuming the typical outline, the fontanels bulging, 
and changes in the eyes, such as undue prominence, strabismus, and the 
usual pupillary symptoms being evident. The tendency in the simple 
(ises is to chronicity, and recovery occurs in perhaps 20%. Many 
serious and permanent impairments may persist, these being chiefly 
deafness, mental defects and blindness. 

CHRONIC MENINGITIS .— The symptoms of this ailment are 
essentially those of chronic syphilis or tubercular disease of the men- 
inges and therefore consist almost wholly of pressure phenomena; any 
form of meningitis may however become chronic. 

CONGENITAL HYDROCEPHALUS.— These cast* cause much 
difficulty in labors and the children usually die within the first four or 
five years, rarely, even extreme degrees do not prevent full mentality 
and reasonably long life; but ordinarily, children are backward, men- 
tally defective, and subject to spastic weakness of the lower extremities 
and perhaps convulsive seizures. 

HYDROCEPHALUS IN ADULTS.— This is ordinarily secondary 
to tumor though possibly in rare instances primary. There may or may 
not be enlargement of the skull through separation of the sutures, the 
symptoms are variable and the disease is not positively diagnosticable. 
During life the most common symptoms are headache, recurring 
attacks of coma, optic neuritis and occasionally, ataxia. 

TUMORS OF THE BRAIN.— Varieties.— About § of tumors of 
the brain are tuberculous, and of these 80% occur in children, whereas 
cysts occur almost exclusively in adults. Sarcomata, usually primary, 
constitute about 20% of which 70% occur in adults; carcinomata of the 
softer sort and usually secondary 7%, of which 75% occur in adults; 
gliomata 15% of which 60% are in adults; gliosarcoma 5%, of which 
80% are in adults. Tuberculosis, rarely primary, is usually secondary 
to some pre-existent lesion and basal in location. Syphilitic tumors, 
always acquired, constitute but 3.7%, 99% of which are in adults. 
These show a predilection for the arteries, meninges and ocular nerves, 
1 are usually small, may be multiple, and tend to extend to the adjacent 
cortex * Cysts are ordinarily the result of hemorrhage or softening, 



* Starr states that gummata are not only rare in children but are never 
inherited and may appear within one year after infection or as late as 
twenty. — " Organic Nervous Diseases," 1903, p. 592. 



GENERAL FACTORS IN RELATION TO TUMOR IDENTIFICATION. 579 



rarely parastic. Gliomata and neurogliomata may be dense, but 
more often are soft or myxomatous and the seat of slight reactive 
inflammation or perhaps cystic changes; they occur most often in the 
substance of the cerebrum, cerebellum or brain stem. Osteomata, 
fibromata and lipomata are rare.* 

Symptoms. — The most suggestive symptoms are: (a). Persistent or 
paroxysmal, often violent, headache, usually at its maximum in the early 
morning, (b). Apparently causeless vomiting most constant in children, 
(c). Optic neuritis, generally double, (d). Mental changes (usually 

apathy), (e). Vertigo, (f). Gen- 
eral or slight convulsions or epilep- 
tiform seizures closely resembling 
either grand mal, petit mal, Jack- 
sonian epilepsy, or even showing 
the psychic equivalents, (g). Pres- 
sure symptoms, irritative or de- 
structive, (h). Syncope. (i). 
Emaciation, (j). Polyuria, (k). 
Insomnia. 

Large tumors in important loca- 
tions may produce no characteristic 
localizing symptoms, or, their order 
and type may be suggestive or 
definitive. Unlike hemorrhage 
they are usually of gradual onset 
and progressive in type though inflammatory reaction may intensify 
them and periods of intermission are common. 

GENERAL FACTORS IN RELATION TO TUMOR IDENTI- 
FICATION.- Tuberculosis.- Three-fourths of all cases occur in 
persons under twenty, 50% in those under ten years of age. A personal 
or family history of tuberculosis, predominance of basal lesion, or if 
Cortical, irritative rather than destructive symptoms. Retinal tubercle 
(laic ami rare). Early progressive symptoms followed by prolonged 
intermission and pontine or cerebellar Localization. 

Syphilis. History or symptoms of acquired, never a congenital 

! Starr's tabic shows that oi 600 rases of brain tumor, [03 were tuber 

culous (15a in children), tao were sarcomatous (86 in adults), 91 were 
gliomata (54 in adults), 30 were gliosarcomatous (25 in children), 3a were 
cysts (adults 30), 4] carcinomatous (31 adults), 33 were syphiliti 
adults), 71 miscellaneous. (^ all these the sarcomata most rapidly invade 

the adjacent tissues. 



Some of 
the more 
prominent 
symptoms. 




Fig. 228. — Choked disc cerebral tumor. 
( Alter Gowers.) 



Often 

svmptom 

less. 

Insidious 
and pro- 
gressive. 



The young 

chiefly 

affected. 



5 8o 



MEDICAL DIAGNOSIS. 



Always 
acquired. 



Adults. 

Sudden 
onset. 



syphilitic lesion, cortical localization and irritative lesions. Rapid 
advance often followed by arrest, headache worse at night. Disappear- 
ance under radical treatment, the effect of antisyphilitic medication* 
Almost exclusively a disease of adults. 

Glioma. — There ' is usually sudden coma followed by accession of 
symptoms, irritative cortical phenomena. 

Sarcoma. — Existence of a primary growth, rapid, progressive and 
diffuse symptoms. Common. 

Carcinoma. — Elderly patients, usually over 50. Primary growth 
present. Local tenderness may be present in cortical tumors. 

Terminal Symptoms of Tumor. — Rapid pulse, dementia, persist- 
ent continuous vomiting and Cheyne-Stokes respiration are sometimes 
present, stupor and coma common. 

Focal Symptoms. f — All lesions may involve other areas by contigu- 
ity, transference of irritation, actual pressure, or invasion. 

Cortex. — Frontal. Impairment of mentality, change of disposition, 
irritability, loss of memory, apathy and somnolence, childishness, fits of 
passion, maniacal outbursts or non-delusional dementia, motor aphasia 
and agraphia (left lower frontal). Parietal. Word blindness (left infe- 
rior parietal), haemianopsia (if occipital lobe is affected), disturbed muscle 
sense and sensation opposite side of body, inco-ordination. Occipital. 
Mind blindness, lateral homonymous hemianopsia. Temporal. Inter- 
cortical sensory aphasia and word deafness (left side). Sylvian Fissure 
and Island of Reil. Pressure exerted by superimposed growths may 
involve internal capsule and cause paraphasia or hemiplegia; infer- 
ior parietal or superior temporal, sensory aphasia; 3rd left inferior 
frontal, motor aphasia; operculum, facial palsy. Motor (Rolandic) 
Area. Jacksonian epilepsy (tonic or clonic convulsions) followed by 
transient, perhaps ultimately permanent paralysis and accompanied or 
preceded by localizing numbness or tingling (the origin and course of 
the spasm indicate the area of involvement); spastic paralysis, i. e., 
increased reflexes, preserved muscle tonus, nutrition and electrical 
reaction. 

Cerebellum. — Median Lobe. Optic neuritis and severe headache 
appear early, staggering gait or propulsive movements, vertigo (when 
upright) or actual falls. Inferior Surface. Associated cranial nerve 
involvement. Middle Peduncles. Unilateral swaying in direction op 

* It should always be tried in doubtful lesions. 

t Largely based upon the admirable descriptions of Starr, Nothnagle 
and Ziehen. 



CEREBRAL HEMORRHAGE, EMBOLISM AND THROMBOSIS. 



581 



posite to growth, or propulsion and cranial nerve involvement on same 
side as lesion. Superior Peduncles. Same as corpora quaclrigemina. 

Corpora Quadrigemina. — Partial, usually unequal and bilateral 
oculo-motor palsy, nystagmus, staggering gait, superior and inferior 
recti chiefly affected, inco-ordination of eye movement, unsteady vision. 
These symptoms are pathognomonic. 

Crus Cerebri. — Oculo-motor paralysis same side, haemiplegia oppo- 
site side with perhaps bilateral hemianopsia (optic tract). 

Pons. — Paralysis of 3rd and 5th nerves (upper pons), hence anaes- 
thesia of face, external strabismus, corneal dryness and ulcer, dilated 
pupil, ptosis, etc. Knee jerks often inhibited. Lower portion. 6th, 
7th and 8th nerve paralysis, internal strabismus, with alternating haemi- 
plegia. Medulla. Hemiplegia, hemianaesthesia, hemiataxia, paralysis 
of related cranial nerves including the hypoglossal, vagus and spinal 
accessory. The wealth of vulnerable structures in this region may 
yield a multitude of diverse symptoms. Ataxia, vertigo, projection 
movements, dysphagia, unilateral or bilateral sweating, vomiting, lingual 
paralysis, cervical retraction, etc. 

Internal Capsule. — If this be affected there is hemianopsia, hemi- 
plegia and hemianaesthesia. Optic thalamus, awkward positions of 
the body and athetoid movements, marked sensory disturbance and, in 
posterior lesions, homonymous hemianopsia; voluntary facial expression 
present, involuntary emotional expression absent. In most cases no 
characteristic symptoms. 

CEREBRAL HEMORRHAGE, EMBOLISM AND THROM- 
BOSIS. — Age. — Cerebral hemorrhage is rare before 40 and the tend- 
1 ency increases with age though cases are occasionally seen in children 
and in young men or women who have a precocious arterio-sclerosis. 
. It is doubtful whether there is much difference in its incidence as between 
men and women. Hereditary predisposition certainly is of the highest 
Importance (see page 47). Chronic alcoholism, lead poisoning and 
syphilis are important antecedent conditions as are gout and nephritis 
because of the associated high pressure and vascular changes. Trau- 
matism and the hemorrhagic diseases such as haemophilia, leukaemia and 
pernicious anaemia must be considered. The acute infections diseases 
exert little influence. Two factors arc essential to the ordinary type o\ 

cerebral hemorrhage, namely, weakened vessels and high VOSCulof tension. 
Hemorrhages may be large and single or punctate and multiple, cortical 
or "capsulo-ganglionic." Arteriosclerosis and atheroma of the senile 

type often associated with an hypertrophied left ventricle furnish most 
38 



Heredity, 

habits ami 
occupation. 
and disease 



Essentia] 



582 



MEDICAL DIAGNOSIS. 



of the cases, and one of the commonest of immediate pathologic causes 
Miliary is the rupture of such miliary aneurisms as may frequently be found 
in the medulla, pons, caudate and lenticular nuclei and optic thalamus, 
the lenticulo striate artery being the chief offender (50% of all cases). 
Other cases may be due to congenital hypoplasia or acute toxaemic 
degeneration. 

Absorption may take place in minor hemorrhages but ordinarily 
the brain tissue is destroyed by softening and the clinical symptoms 
depend both upon the position of the clot and its extent. Any hemor- 
rhage that reaches the 4th ventricle will of course produce almost 
instant death. By extension from the neighborhood of the internal 
capsule exuded blood may reach and fill any of the ventricles. Cortical 
lesions result from similar lesions of the Sylvian artery and occasionally 
the pons or even the cerebellum may be the site of the rupture. 

Exciting Causes. — Violent muscular strain, the sexual act, labor, 
defecation, fear, anger, joy and similar physical strains or emotional 
states most frequently excite an attack, but more often no definite 
cause can be assigned. 

Premonitory Symptoms. — Usually none are present, occasionally 
numbness, prickling or formication in the lower extremities, transient 
visual disturbance, irritability, headache, vertigo, drowsiness, or insomnia 
may be noted before the attack.* Unilateral choreiform movements 
and spasm of the ocular muscles are rare, and in many instances such 
symptoms undoubtedly indicate a slight antecedent hemorrhage. f 
There are two distinct types of seizure, the sudden and the gradual, 
the former furnishing the typical cases of " apoplectic insult" or "stroke." 

Symptoms of Attack. — Loss of consciousness is immediate and 
complete, the face congested or ashen and cyanotic. All voluntary 
muscles are relaxed, the pupils may be moderately dilated, irregular, 
or, in ventricular or pontine hemorrhage, contracted. The pulse is slow, 
full and of high tension. There may be conjugate deviation towards 
the lesion and the temperature is normal or more usually subnormal. 



Congenital 
or toxaemic. 

Absorption 

vs. 
Softening. 



Hemor- 
rhage into 
ventricles. 



Cause 
evident or 
absent. 



Signal 
symptoms. 



" Insult " 
or "stroke." 



Striking 
signs. 



Eye symp- 
toms. 



* In a case recently observed two attacks of momentary unconsciousness, 
mental confusion and sensory aphasia with barely perceptible transient 
tremor of the left hand were followed in a few days by an apoplectic seizure 
producing instant death. In another, on two occasions, the patient fell 
suddenly to the floor without stumbling or tripping, arose immediately, 
showing neither loss of consciousness, mental confusion or motor weakness, 
only to die instantly a few weeks later as in the preceding case. In one 
embolus seemed probable, in the other true apoplexy. 

f The author has seen a number of cases in which ocular hemorrhages 
shortly preceded an apoplectic seizure. 



CEREBRAL HEMORRHAGE, EMBOLISM AND THROMBOSIS. 



583 



Respirations are slow and stertorous, the cheeks are blown outward 
with each expiration, and facial paralysis may be indicated by the 
greater excursion of the paralyzed side. The lips are relaxed, spluttering 
and foam covered. In cases of gradual onset, paralysis and loss of 
consciousness may not appear for several hours. 

Second Stage. — After a period varying from a few hours to one or 
two days there is a febrile inflammatory reaction lasting from one to 
7 or 8 weeks. A preagonal hyperpyrexia or drop to subnormal usually 
indicates extending hemorrhage, rupture into the ventricle or involve- 
ment of the medulla or pons. After a variable period consciousness, 
and usually to some extent motor power return while in the limbs that 
remain paralyzed early rigidity develops. Trophic changes chiefly in 
the form of bed sores, and congestion of the lungs may add to the gravity 
of the case. It is important that paralysis should be recognized in the 
cases of coma, as it often at once differentiates apoplexy from other 
conditions. Ordinarily, it is only necessary to raise the arms and 
legs and note the comparative resistance offered to passive movement 
and the change in the tonus as indicated by the dropping of the lifted 
arm or leg. Facial paralysis is readily noted and eye symptoms such 
as conjugate deviation at once suggest the cause.* Loss of power 
may be complete and include the opposite half of the body including 
the area of the facial and hypoglossal nerve; or, incomplete, the face being 
unaffected. If the ventricles be affected tonic rigidity or marked con- 
vulsive seizures may occur. The reflexes are entirely abolished during 
coma, though greatly increased when the first shock of the attack has 
passed, and the theory of suspended function through shock seems a 
sufficiently reasonable explanation of this departure from the law that ' 
governs reflex action. 

Residual Symptoms.- The superficial reflexes are absent perman- 
ently or for long periods over the affected side. Conjugate deviation 
is usually transient but occasionally persists for weeks or months and 
in these eases there is probably a direct lesion o\ the inferior parietal 
lobule. In residual paralyses we ordinarily find crossed hemiplegia, 
usually most marked in the leg and least in the trunk with increased 
patellar reflexes. There is unilateral lagging of the thorax. In respira- 
tion the shoulders drop downward, yet the muscles read normally to 



Larval 
cases. 



Reaction. 

Hyper- 
pyrexia. 



Remission. 



Trophic 
changes. 



Signs of 
paralysis. 



Ventricular 
symptoms. 



Reflexes. 



iupei ficial 
eflexes. 






*The most frequenl sourer of hemorrhage is the Lenticulo striate region, 
a crossed hamiplegia being produced rather by pressure than actual 
destruction which accounts for the marked diminution in extern and degree 
o! paralysis so frequently following apoplectic insult. 



^ 



584 



MEDICAL DIAGNOSIS. 



Aphasia 
and dys- 
phasia. 



Hemi- 
plegic 

vs. 
Spastic 
gait. 



Arthritis. 



Secondary 
degenera- 
tion. 

Hemianes- 
thesia. 



Relative in- 
volvement. 



Athetosis. 



Indefinite 
in early 
stage. 



Important 
focal signs. 



the electric current and their atrophy is that of disuse. Speech is 
restored either entirely or to a considerable degree, often very early, but 
dysphasia may persist for some time. The well known hemiplegic 
gait is due to the patient's throwing the balance of the body constantly 
towards the sound side, the affected leg swinging outward and striking 
the ground in a flail like manner. Later flaccidity is replaced by spas- 
ticity, when, as a rule, predominating extensor contraction and a typical 
spastic gait appears (see page 35). Usually improvement in the leg 
is more rapid than in the arm and in the latter spastic contraction 
produces flexion of both elbows and fingers. A low grade arthritis 
from disuse is frequent with pain and partial anchylosis, symptoms of 
vaso-motor paralysis may appear and a secondary descending degen- 
eration may intensify the deep reflexes even of the sound side. Hemi- 
anaesthesia affecting pain, temperature and touch is present though 
imperfect and ordinarily transient. // marked and persistent it con- 
stitutes a direct focal symptom. Muscle sense is less often affected 
but disturbances of vision and aphasia may be indirectly produced, 
and be transient or focal, persistent, or even permanent. Facial paral- 
ysis usually affects only the lower branches; the muscles of the neck 
and trunk are relatively less affected than those of the extremities and 
the hypoglossal paralysis is seldom complete. Choreic or athetoid 
movements may appear during the regenerative stage and usually 
indicates a focus in the posterior part of the internal capsule or the 
adjacent optic thalamus. 

Localizing Symptoms. — As regards the localizing symptoms it 
must be remembered that correct localization is seldom possible in the 
earlier stages of an apoplexy. The persistence of a hemianesthesia 
suggests a focal lesion in the posterior portion of the internal capsule, 
the central convolutions or the intermediate medullary tissue. Mono- 
plegia indicates a lesion of the centrum ovale, cortical motor centre, or, 
a central paralysis of such nerves as the facial and hypoglossal if these 
are alone affected. If aphasia complicate a monoplegia a cortical 
lesion is most probable, if aphasia be absent the centrum ovale is sug- 
gested. If hemiplegia is associated with cranial nerve paralysis of the 
opposite side from the 5th backward, a lesion of the pons or pons- 
medulla on the side of the cranial nerve paralysis is probable. If 
ocular motor alternating paralysis co-exists with hemiplegia a lesion of 
the peduncular tract is suggested. Hemorrhage into the internal 
capsule generally produces complete hemiplegia. 

Differential Diagnosis. — Symptomatic apoplexies, that is those 



THE DIFFERENTIAL DIAGNOSIS. 



58s 



pseudo-apoplectic seizures that occur in the course of such diseases 
as cerebral tumor or abscess and paralytic dementia may present the 
greatest diagnostic difficulty, though in most instances such a case 
history is known or obtainable as at once suggests their true nature. 
Absence of choked disc helps to exclude brain tumor. If hemianacs- 
thesia appears it is usually transitory. Certain epileptic seizures 
resemble apoplexy but the subsequent course and previous history 
usually suffice. 

Uraemia. — An immediate diagnosis is often impossible even in the 
presence of urinary signs of renal disease. Convulsions are more 
likely to occur as an initial symptom of uraemia and the subsequent 
course is usually distinctive, uraemic paralyses being rare. Meningitis. 
This condition often offers serious difficulties particularly as certain 
apoplexies are associated with painful contraction and rigidity of the 
neck muscles. The persistence of convulsions, their bilateral incidence, 
the general hyperaesthesia, the possible demonstration of optic neuritis 
and the history and course of the case must be depended upon as indi- 
cating meningitis. Acute sepsis may produce pseudo-apoplexies but the 
clinical picture soon becomes distinct. Hemorrhagic pachymeningitis 
if unilateral cannot be differentiated from a cortical hemorrhage of 
slow onset. 

Hysteric Hemiplegia. — Hysteric paralyses are usually shifting and 
transitory and seldom involve the facial nerve or produce hemiopia. 
Sensation is markedly and usually atypically affected as compared with 
apoplexy. (See p. 615.) There are usually visual, olfactory and audi- 
tory disturbances or hallucinations and as a rule the well known hys- 
teric stigmata make the diagnosis. As regards the secondary changes it 
cannot be decided positively by any known diagnostic test whether in a 
given case these are due to cerebral softening or to cerebral hemorrhage. 
Finally it cannot be too emphatically repeated that focal disturbances 
cannot be correctly localized during the apopletic seizure and judgment 
must in every case be suspended until the various and confusing indirect 
symptoms have had an opportunity to subside. 

THE DIFFERENTIAL DIAGNOSIS BETWEEN CERE- 
BRAL HEMORRHAGE AND EMBOLISM. This depends almost 
entirely upon a consideration of the factors of antecedent disease and 
sometimes the age, as the symptoms of an actual attack are so nearly 
alike as to render positive differential diagnosis impossible in mosi 
cases. Most important is disease of the heart, oil her rheumatic, 

arteriosclerotic, myocardial, aneuiismal or mere cardiac weakness. 



Case his- 
tory helps. 



Condition 
of disc. 



Ursmic 

paralyses 

rare. 



Antecedent 
disease of 

tlu- heart. 



5 86 



MEDICAL DIAGNOSIS. 



Associated 
conditions. 



Heart 
murmur. 



Mode of 
onset. 



Mental 
state. 



Primary 

vs. 
Secondary 



Seek causa- 
tive factors 



The attack may come on during quiet sleep, be transient and quickly 
recovered from and not infrequently there is a history of antecedent em- 
bolism in other portions of the body. In certain cases a marked and 
sudden change in the character of the heart murmur may suggest the 
detachment of a particle of vegetation or auricular clot. A large num- 
ber of differential symptoms are given by different authorities, but 
neither the author's experience nor his knowledge of the conditions 
attending the two lesions lead him to give them any important place. 
The significant fact that 90% of all cases of embolism depends upon an 
antecedent lesion of the left heart points the way to differential diag- 
nosis. 

THROMBOSIS. — This lesion may be entirely symptomless even 
when not occurring in the so-called " silent " regions. The localizing 
symptoms and resulting paralysis are so nearly alike in thrombosis, em- 
bolism and hemorrhage as to permit no accurate differentiation from 
I this standpoint. The mode of onset of the paralysis in thrombosis is more 
suggestive, the symptoms being far less violent, coma seldom present 
and consciousness being as a rule either wholly or partially retained. 
Mental symptoms are much more pronounced than paralytic symptoms 
after the attack and usually assume the form of general mental impair- 
ment with marked irritability and a tendency to emotional excitement. 
Finally the differential diagnosis of these diseases is assisted by the 
fact that 80% of the so-called apoplectic attacks are chargeable to cere- 
bral hemorrhage, and the physician's mind is also comforted by knowl- 
edge that an immediate differential diagnosis is of little importance to 
the patient. 

CEREBRAL ABSCESS.— It might be thought that cerebral abscess 
would present striking general symptoms which differentiated it from 
cerebral tumors and other confusing lesions. Such, however, is not the 
case save in exceptional cases, and the diagnosis ordinarily depends 
more upon the recognition of one of the well known causative factors 
than upon any specific or exclusive symptomatology. Of such causes we 
may enumerate traumatism- with or without fracture, suppurative dis- 
eases of the scalp, empyema, pulmonary cavities and most important of 
all chronic suppurative otitis media, a condition frequently associated 
with mastoiditis and caries. Abscesses so caused are most frequently 
in the cerebellum, whereas, when from other causes, they chiefly affect 
the cerebrum, abscesses of the basal ganglia or brain stem being rare. 
The accumulation may be superficial or within the substance of the 
brain, and 80% are single; multiple abscesses resulting usually from 



PARALYTIC DEMENTIA. 



587 



remote foci uch as empyema. In size they vary usually from 2 cm. 
to 8 cm. 

Symptoms. — Extraordinarily latent cases have been reported which 
for several months or years yielded few or no indications of their presence. 
More often the symptom-complex is essentially that of brain tumor and 
consists largely of pressure phenomena. In acute cases following 
operation or injury or in those secondary to an otitis media, the symp- 
toms a e primarily those of a meningeal inflammation, and there may 
be fever, chills, vomiting, delirium and severe headache, perhaps preceded 
by symptoms that are irritative in character. In the latter stages of 
abscess, mental torpor, drowsiness and optic neuritis are common, a 
period of latency is the rule in cases which arise from distant foci and 
not uncommonly from those due to direct injury. The localizing symp- 
toms are, of course, less distinct than in tumor but follow the same 
rules. Fever is very often entirely absent, is often overlooked when 
present, if the primary disease be febrile and not infrequently there is 
subnormal temperature. It is evident, therefore, that it is only by a 
combination of suggestive etiological factors, the symptoms of intra- 
cranial pressure and perhaps of septic absorption, that a differential 
diagnosis is made. MacEwen's method of skull percussion is more 
likely to yield results in abscess than in any other condition producing 
intracranial pressure. The increased resonance obtained depends upon 
a distension of the lateral ventricles and compression of the venae 
galeni. Optic neuritis is far less constant than in brain tumor or 
( meningitis. 

PARALYTIC DEMENTIA.— (General paralysis of the insane), 

I (general paresis). Etiology. — The etiologic factors of general par- 

, esis are identical with those of locomotor ataxia and by the diseases 

j seem to differ only in the seat of the morbid process, though alcoholic 

j excess seems to be more important in the former than in the latter. 

Morbid Anatomy. — Amongst the multitude of diverse findings are: 

a small brain with shrunken convolutions, sclerotic arteries, hyper- 

semia, edema, hypertrophic pachymeningitis, thickened and adherent 

I pia, an increase of cerebro-Spinal fluid with dilatation o\ the 4th and 
I lateral ventricles with granular ependyma. "Microscopically there is 

general neuroglia overgrowth with degeneration of cells and fibre 

atrophy, and changes may sometimes be found in the spinal cord iden- 
tical with those of locomotor ataxia. The whole brain is involved 
though in varying degree. 
j Symptoms. As in locomotor ataxia we deal with a parasypkUiHc 



Larval 
cases. 

Hrain 
tumor 
symptoms. 



Meningeal 
form. 



Fever. 



Skull per- 
cussion. 



Optic 
neuritis. 



A disease 

of adult 
males. 

Parasyphil- 

itic. 



5 88 



MEDICAL DIAGNOSIS. 



Syphilis 
chief factor 



Neuras- 
thenic 
symptoms. 

Change of 
character. 



Garrulity. 

Delusions 
of grandeur 



Outbreaks. 



Impaired 
memory. 



Writing 
and speech. 

Knee jerks. 
Pupils. 



Various 
symptoms. 



Dementia. 



progressive degeneration ending in general exhaustion and palsy, 
but, unlike its congener, associated with marked mental symptoms 
and terminal dementia. It may be divided into two stages, to which 
some add a prodromal stage, and varies considerably in type. 

First Stage. — The early symptoms of this stage are significant but 
not distinctive, being identical with those of certain forms of neuras- 
thenia. A change of character is soon evident, carefulness, good nature, 
self restraint, frugality, good judgment, high ethical standards, concen- 
tration, vigor and modesty, give place to carelessness, in matters large 
and small, peevishness, irritability, or violent outbreaks of temper, 
periods of extravagance and foolish investment, coarseness and perhaps 
brazen immorality. The victim is inattentive to occupational and domes- 
tic duties and obligations, tires easily and lacks concentration and ability 
to perform sustained work. He is garrulous, egotistic yet jocose and 
loud in voice and manner. Delusions of grandeur shortly appear and 
the patient deals only in superlatives. His enormous wealth, marvel- 
ously simple yet grandiose schemes, his house, his wife, his children, 
his wonderful self are all beyond compare. Violent outbreaks may 
occur in this latter period of the first stage, often associated with drinking 
bouts and with sexual excesses often marked by extreme perversion. 
In the later period of this stage or even during the earlier exaltation 
period lapses of memory may occur, the handwriting may be uncertain, 
letters lack coherency, errors in figuring occur and one notes tremor 
of the facial muscles and tongue, difficult enunciation of consonantal 
words such as " British Constitution," the speech being hesitant, slurring 
or even stuttering. The knee jerks are increased and the pupils often 
sluggish and unequal or even of the Argyll-Robertson type. Attacks of 
vertigo or syncope, pseudo-apoplexies with hemiplegia, or transient epilep- 
tiform seizures may occur and insomnia may be troublesome and 
intractable but true apoplexy is uncommon in this stage. Sexual weak- 
ness and loss of vesical power may be manifest but the vegetative func- 
tion may be long preserved and the appetite is often gluttonous. 

Second Stage. — This is the stage of decided and increasing de- 
mentia, memory, even for familiar faces and common events, becomes 
fitful and almost lost. Personal cleanliness is neglected, there is slob- 
bering at meals and a gradually increasing dependency. Apoplectiform 
attacks are followed by permanent paralysis, hemiplegic in type, and 
true apoplexy may supervene and terminate the case. The duration 
of this form is extremely variable, the stage of dementia being usually 
reached in a few months after the appearance of pronounced mental 



ANEMIA OF THE CORD. 



589 



symptoms. Death occurs sometimes within a year, but may be post- 
poned for 15 or 20. Remissions are not infrequent but entire recovery 
usually means an error in the diagnosis. 

Variation in Type. — Dementia is sometimes primary, the period of 
exaltation and excitement being entirely lacking. In such instances 
the premonitory symptoms are almost precisely like those of pronounced 
neurasthenia, in other cases a marked hypochondriasis is substituted 
for exaltation. In some of these cases there is much complaint of 
dull pain in the head, trunk and other extremities. Other cases are of a 
primary exudative type evidenced by primary ocular palsies or cephal- 
algia with convulsive seizures. These cases are of especial interest because 
of the fact that terminal symptoms of dementia are often postponed 
for five or ten years. Of equal importance are those cases of tabo- 
! paresis presenting a combination of locomotor ataxia and paretic dementia. 
1 In these the onset may be primarily that of a locomotor ataxia, or, such 
as to immediately suggest the combined lesion. When the cord symp- 
toms are pronounced the brain symptoms are usually delayed and vice 
versa. It must be remembered that various forms of mental disease 
other than general paresis may complicate tabes dorsalis. 

Differential Diagnosis. — The earliest stages of paralytic dementia 

in its ordinary form cannot be made the basis of an absolute diagnosis 

without risking a serious and dangerous error in diagnosis. Practically 

every symptom may be found in curable cases of neurasthenia and 

in chronic alcoholism. With the appearance of pupillary symptoms 

and marked tremor of the face and tongue, or marked and characteristic 

exaltation, the clinical picture is greatly cleared. Furthermore, cases 

I of pure cerebral syphilis exactly simulate one form of tabes and may 

. lead to error. A differential diagnosis may be impossible in such instances 

\ for a considerable length of time, pending the result of active and radical 

. specific medication. 

Cyto-diagnosis.— In both tabes and paresis the spinal fluid contains 
a considerable amount of albumin and an excess of lymphocytes, but 
the value of the finding is limited to the proof that it offers of B subacute 

. or chronic inflammation as contrasted with the polymorphonuclear 

leukocytosis Of an acute inflammation. However, it fortunately occurs 

earl)/ in the disease, and may thus greatly assist the diagnosis. 

ANjEMIA OF THE CORD. Only in the most profound acute 
and chronic aiuenu'as (\o symptoms from the cord manifest themselves 
In pernicious afucmia hemorrhage may occur or even a true postero 
lateral sclerosis. Cord symptoms of severity mav follow a great loss 



Duration. 
Remissions 



Primary 
dementia. 



Hypochon- 
dria. 

Cephal- 
algia. 

Primary 
cerebral 
palsies. 



Tabo- 
paresis. 



Cord 
vs. 
Brain 
symptoms. 



Early ac- 
curate 
diagnosis 

impossible 



Cerebral 

syphilis. 



Early 
findings 



59° 



MEDICAL DIAGNOSIS. 



Adult 
males. 

Parasyphil- 
itic. 



Degenera- 
tion of 
sensory 
structures. 



Pupillary 
signs. 

Dysuria 
and incon- 
tinence. 

Knee and 

Achilles 

jerks. 



of blood and on the other hand marked changes may be found at autopsy 
which have yielded no symptoms during life. The diagnosis can 
seldom be made save tentatively and is based upon the presence of 
anaemia as an etiological factor together with localizing symptoms. 

THROMBOSIS, EMBOLISM, ENDARTERITIS OF THE 
CORD. — However important these conditions may be as the prim- 
ary factor in certain degenerative changes they are by themselves of 
no clinical importance. 

LOCOMOTOR ATAXIA.— (Tabes dorsalis), (posterior spinal scler- 
osis). Definition. — A disease characterized by a gradual onset and 
prolonged course, associated with loss of the deep reflexes and normal 
pupillary light reaction, visceral crises, inco-ordination, lightening pains 
and ultimate paralysis. 

Etiology. — // is essentially a disease of the male, more common in 
the white than in the colored race, occurs most frequently between the 
ages of 30 and 50, and is so generally associated with a past history oj 
syphilis as to justify the belief that at least 90% of the cases are thus 
explained. Alcoholic and sexual excess, exposure, fatigue and injuries 
are occasional associated conditions, but are probably not causative 
and usually not even contributory. Aside from hereditary syphilis 
which occasionally causes the disease in children, heredity plays no 
part. 

Morbid Anatomy and Pathology. —Much confusion exists and no 
definite statement as to the exact cause of the pathological changes 
is possible. // is essentially a posterior spinal sclerosis involving 
primarily the larger dorsal root fibres, though changes in the blood 
vessels of the nerve roots, pia mater and cord may appear early. The 
disease is a progressive degeneration and even though the primary 
lesion is not in the cord itself, the major changes are ultimately to be 
found there, and even macroscopic examination reveals the morbid 
condition in most instances. 

Symptoms. — (Incipient stage). Eye Symptoms. The Argyll-Robert- 
son pupil showing a loss of the iris reflex to light, with normal reaction 
to accommodation, is one of the earliest symptoms. The pupils arc 
often contracted, perhaps unequally so, and there may be optic atrophy, 
ptosis, paralysis of the external recti or even total blindness. Dysuria. 
This is an early symptom, whereas incontinence occurs later in the 
disease. Loss of Deep Reflexes. Early in the disease the knee jerk is 
diminished and finally lost, the response being often unequal on the two 
sides until both are abolished, and the Achilles jerk may be lost first. 



LOCOMOTOR ATAXIA. 



591 



Pain. — The characteristic lightening pains are acute, darting, stabbing, 
follow dorsal root areas, are irregular in occurrence, variable in intensity, 
likely to be initiated by excesses of any kind and leave as suddenly as 
they appear. They most often affect the legs, but may occur in the 
arms, head or trunk, and sensitive areas and herpetic eruptions may 
follow them. 

Ataxic Stage. — Romberg's sign is one of the earliest, the patient 
being unable to stand steadily with the feet together and the eyes 
closed. Furthermore, he cannot stand on one leg or start off promptly 
when ordered, his turns are made laboriously and cautiously and 
descending stairs is difficult. It may be present in the first stage and 
antedate the loss of knee jerks. The characteristic gait (ataxic) devel- 
ops later, the patient throwing out the leg with jerky, uncertain action, 
keeping the feet far apart to secure a wider base, and bringing them 
down heel first with a sort of stamp; being obliged ultimately to use 
one or even two canes or totally disabled. Inco -ordination is less 
prominent in the arm movements than in those of the leg and muscle 
power is remarkably preserved, as is nutrition, until the later stage of 
the disease. There is unusual mobility and relaxation of the joints 
which occasionally appears at a comparatively early stage. Various 
sensory symptoms develop during the ataxic period, most marked in 
the lower extremities, the patient feeling often as if the feet were 
muffled in cloths or cotton and losing the sense of the resistance of 
the ground. Sensations of numbness and tingling are prominent and 
lightening pains may or may not exist in varying degrees of severity. 
Not only is the tactile sense impaired but the sense of pain as well, and 
this is associated with a marked retardation of pain transmission so 
that several seconds may elapse before the prick of a pin is perceived. 
Oddly enough ataxic symptoms arc unusual or at least greatly delayed 
in those cases in which optic atrophy is an early sign (one in ten). 

Visceral Crises. These remarkable symptoms constitute a frequent 
source of error in diagnosis and may be gastric, intestinal, rectal, renal, 
urethral, clitoral or laryngeal and associated with marked pain in and 
Junctional disturbances of the parts affected. At this stage incontinence 
of mine may displace simple dysiuia or retardation, cystitis and even 

pyelo nephritis ma) occur; sexual power, diminished in the early stage, 

is now usually lost, and simple constipation niav he replaced by critical 

rectal pain and spasm and ultimately by relaxation of the sphincter. 

Trophic Changes. Perforating ulcer of the foot and the so-called 

Charcot's joint are the most prominent o\ these changes. The former 



Often 

misinter- 

preted. 



Static 
ataxia. 



Ataxic gait. 



Incoordi- 
nation. 

Muscular 

power. 

Joints. 



Anaesthesis 

Paresthe- 
sia. 

Analgesia. 



Signifi- 
cance of 
optic 
atrophy. 



Mislead- 
ing. 

I "nn.iry 

and rectal 
s\ mptoms 



Charcot's 
joint and 
perfoi .uun 



592 



MEDICAL DIAGNOSIS. 



Cutaneous 
symptoms. 



Loss of 
power 

delayed. 



Long 

duration, 



Typical 

cases 

simple. 



Also pos- 

tero-lat- 

eral. 



appears usually on the sole of the foot beneath the great toe, the latter 
is a painless disintegration of the joint associated with effusion, deformity 
and tendency to dislocation. The bones are brittle in this disease and 
spontaneous fracture may occur. Various skin rashes, areas of 
sweating, herpes and edema may appear in connection with lightning 
pains. Muscular atrophy seldom appears until late in the disease 
but the nutrition of the nails may be greatly affected. Brain Symptoms. 
Paranoia, melancholia, and dementia may occur, and paralytic dementia 
is "cerebral tabes," the difference being merely one of localization. 
Duration. Paralyses are seldom marked until from 5 to 8 years have 
elapsed; even then progress is slow, periods of apparent arrest not un- 
common, while actual arrest sometimes occurs. The chronic course 
of the ailment is remarkable, the patient may live for 25 or 30 years, 
though rarely cases occur in which the progress of the disease is rapid. 
Death results from intercurrent disease in nearly every instance. 

Differential Diagnosis. — Tabes need seldom be confounded with 
any other disease, the combination of loss of deep reflexes, the Argyll- 
Robertson pupil and lightening pains making a distinct clinical picture. 
In true ataxic paraplegia the knee jerks are increased, in chronic multiple 
neuritis with ataxia ("pseudo-tabes") there is marked muscular atrophy 
and tenderness over the affected nerves. 

ATAXIC PARAPLEGIA.— (Gower's disease, postero -lateral scler- 
osis, etc.). A combination of marked inco -ordination and slowly devel- 
oped spastic paraplegia with retained and increased reflexes and fre- 
quently ankle clonus makes a clean cut clinical picture. It is associated 
with degenerative changes in the dorsal and lateral columns of the 
cord and is of unknown causation. The sphincters are usually in- 
volved, there is a late development of mental symptoms similar to 
those of paretic dementia, and cranial nerve symptoms are seldom 
pronounced. There may be " dull aches," rarely lightning pains. 

PRIMARY COMBINED SCLEROSIS.— This name has been 
given by Putnam to cases presenting clinically progressive weakness, 
numbness of the extremities, exaggerated tendon reflex, spastic contrac- 
tion and paraplegia with pronounced anamia. 

HEREDITARY ATAXIA.— (Friedreich's ataxia). This disease 
of childhood or young adults needs another name as it is not invaria- 
bly hereditary. It is associated with degeneration of the dorsal and 
lateral columns of the cord. 

Symptoms. — The chief features are marked in co-ordination involving 
first the legs, but later the arms, and these to a marked- degree. The gait 



k N 



CEREBELLAR HEREDITARY ATAXIA. 



593 



is uncertain and staggering rather than stamping. Arm movements 
lire jerky and irregular, grasping involves pouncing upon the object. 
\Tendon reflexes are diminished or lost, there is early talipes equinus, the 
\]>ig toe becomes flexed dorsally, nystagmus occurs. Pupillary reactions 
lind the optic nerve are unafjected. Paralysis and mental impairment 
^usually come on late. The speech is indistinct, slow and scanning. 

CEREBELLAR HEREDITARY ATAXIA.— (Marie). This later 
aife form of hereditary ataxia, presumed to be associated with a congen- 
ital cerebellar defect, is characterized by impaired pupillary reaction, 
[exaggerated tendon reflex, clonus, ocular palsies, optic atrophy, and, its 
[development in the third decade. Inco -ordination, nystagmus and scan- 
ning speech are present as in Friedreich's ataxia, but the gait is more 
distinctly reeling and drunken. It is doubtful if any line should be 
] drawn, as in the two diseases the same general tracts are affected, the 
spine in Friedreich's ataxia, the cerebellum in that of Marie, the actual 
j tracts being structurally continuous. 

PRIMARY LATERAL SCLEROSIS.— (Spastic paralysis of the 
^adult). This is a disease of early adult life, most common between 
jjthe ages of 20 and 40, no definite etiologic factors have been proven 
^and the pathologic change is essentially a degeneration of the pyram- 
idal tracts, either primary or secondary. 

1 Symptoms. — Muscular rigidity and weakness are often associated 
with dull pain and a persistent sensation oj jatigue and rigidity and im- 
pairment oj locomotion slowly increase and are out oj proportion to the 
loss oj power. The spastic gait is marked early in the disease and later 
becomes extreme, the patient shuffling along with toes dragging, tripping 
over every obstacle, the legs being closely approximated or even so crossed 
that locomotion is lost. The knee jerk is extremely active, Babinsky's 
.sign, rectus and ankle clonus are easily elicited, superficial reflexes are 
increased and in some instances clonus appears whenever the foot is 
^placed upon the ground and the slightest touch may produce clonic 
spasm of the legs. The latter may be equally or unequally affected and 
the arms are usually free until the disease is far advanced. The ail- 
ment is one oi long duration, yet nutrition is remarkably preserved. 

sensation is not affected and the sphincters are rarely involved until 
late in the disease. Ultimately an extreme state of disabling contrac 
ture and atrophy from disuse develops. Diagnosis is never positive, as 
primary sclerosis is excessively rare and eases usually prow to be see 
ondary. 
Secondary Spastic Paralysis. It is hardly possible to separate 



Spasm and 
lost power. 



Spastic 
gait. 



Increased 
re ilexes. 



Atrophy 

terminal 
onlj . 



ar"" 



594 



MEDICAL DIAGNOSIS. 



Heredity 
and age 
important 
factors. 



Spastic 
type. 

Infancy. 

Normal 

sensation. 

Increased 

reflexes. 



No atrophy 



No R. D. 



Backward- 
ness and 
mental 
defects. 



Rigidity 
and spasm. 



Oscillation. 
Athetosis. 



Slight 
rigidity. 



Involve- 
ment of 
sphincters. 



secondary from primary spastic paralysis which may result from any 
condition producing a lesion in the pyramidal tract, i. e., compression, 
tumor, caries, etc. 

HEREDITARY SPASTIC SPINAL PARALYSIS.— (Hereditary 
spastic paraplegia), (family form of spastic spinal paralysis). This 
variety is distinguished from infantile spastic paralysis chiefly by its 
distinctly hereditary nature and the fact that it commences several years 

i after birth, usually at about the age of 5. Two groups are distin- 
guished, viz.: — those with the symptomatology of a cerebral spastic para- 
plegia developed in infancy and childhood, but lacking all other cerebral 
symptoms, and those developing in early adult life insidiously with 
primary spasticity and late paralyses. 

THE SPASTIC PARALYSIS OF INFANTS.— (Birth palsy), 
(spastic cerebral paraplegia), (Little's disease), (spastic diplegia). This 
condition is essentially a general spastic paralysis occurring at or shortly 

: after the time of birth, more rarely following a convulsive seizure or an 
acute disease. The legs are chiefly affected without marked sensory 
disturbances or wasting and the reflexes are increased. Athetosis and 
ataxia are extreme and the mental condition markedly affected. The 
condition is no doubt most often due to meningeal hemorrhage and 
the interference with mentality will depend upon the extent and loca- 
tion of the effusion. In cases of premature birth spastic paraplegia 
without mental symptoms is thought by some to be due to an imperfect 
development of the pyramidal tracts. In most instances, however, the 
disease is associated with instrumental delivery and seems to be due to 
actual injury. 

Backwardness of the child may first call attention to the condition, 
or there may have been repeated convulsive seizures. The head may 
seem badly supported, the child may not be able to sit up and shows no 
tendency to walk or creep at the proper age. Leg rigidity and adductor 
spasm are usually marked. Symptoms are commonly either absent 
or less marked in the arms; when marked it constitutes a spastic 
diplegia. Constant irregular larger movements of a choreic type may 
be present in the extremities, sometimes most marked when co-ordinate 
movement is attempted and pronounced bilateral athetosis is often 
present. 

Erb's Syphilitic Spinal Paralysis. — The leading features are slight 
muscular rigidity, exaggerated deep reflexes, pain and sensory disturb- 
ance trifling, involvement of the rectum and bladder, impotence, a slow 
onset and a certain amenability to treatment. 



HYSTERICAL SPASTIC PARAPLEGIA. 



595 



HYSTERICAL SPASTIC PARAPLEGIA.— Hysterical persons 
can accurately simulate true spastic paraplegia and differentiation is 
sometimes extremely difficult, but a few positive points can be laid 
, down. Such are: spurious clonus, more marked and irregular disturb- 
> ances oj sensation, variability in the site and intensity of paralysis, and 
. unsustained or irregular resistance to passive movements, and the fre- 
quent association of hysterical stigmata such as aphonia, meteorism, 
and excessive tenderness in hysterogenic zones. 

AMAUROTIC FAMILY IDIOCY.— The chief characteristic of 
this form of infantile paralysis affecting children during the first or 
second year of life is the constancy of blindness, first, 
partial, later, complete, associated with optic atro- 
phy. The children become idiots and either spastic 
or flaccid paralysis may develop. It is a family 
disease, kills usually before the end of the second 
year, and is sometimes associated with auditor} 7 
disturbances, strabismus and nystagmus. 

SYRINGOMYELIA.— Pathologically, this disease 
consists in the formation of embryonal neurogliar 
tissue which undergoes hemorrhagic or degenerative 
changes, resulting in an enlargement of the central 
canal of the spinal cord quite distinct from ordinary 
dilatation; it is a disease of early adult life, almost 
invariably involves the cervical region, sometimes 
assumes a family type and affects men much more 
frequently than women. A most pronounced diag- 
nostic feature is a loss of thermal and painful sensa- 

^ (After M. Allen H on without marked involvement of the tactile or 
Starr.) m ' 

muscle sense. This is usually accompanied by pain 
•< in the extremities and cervical region, followed by peripheral muscular 
! atrophy of the hands, slowly extending centrally. Scoliosis is usually 
present, the legs may, late in the disease, present spastic paraplegia 
and cutaneous disturbances both trophic' and vaso-motor are common. 
Such are dry or sweating skin, congestion or edema of the extremities, 
especially the hands, bullous or herpetic eruptions, atrophy and disin- 
tegration of the nails, erosions, fissures and ulceration of the terminal 
phalanges. It should be noted that these cutaneous lesions are painless. 
Spontaneous fractures and arthropathies may occur and late in the 
disease the vesical, rectal and genital centres may be involved and 
bulbar symptoms appear. Reflexes are usually increased and fre- 




Spurious 
clonus. 



Peculiar 
resistance. 



Blindness 
and idiocy. 



Death. 



Fig. 229.— Anaes" 
thetic area common 
in hysterical para- 
plegia. The geni- 
tals are spared. 



Cervical 

region 

chiefly. 



Dissociated 
anaesthesia. 



Spinal 

s> mptoms. 



Painless 
cutaneous 

lesions. 



596 



MEDICAL DIAGNOSIS. 



Mixed 
types. 



Varieties. 



Seek cause. 
Note pain. 



Brown- 
Sequard 
type. 



Causes. 



quently the general aspect is that of amyotrophic lateral sclerosis, 
though if the dorsal columns are involved, tabetic symptoms may 
be marked. Clinically, one may encounter a straightforward type 
lacking the predominance of confusing motor or sensory changes, 
or the picture may be that of amyotrophic or spastic paralysis, 
tabes, hysterical hemiplegia or a type in which trophic changes pre- 
dominate. 

MYELITIS. — May be acute, subacute or chronic and the term is usu- 
ally confined to a lesion involving both gray and white substance, 
poliomyelitis and focal (involving a limited area) myelitis being sep- 
arately considered. As regards the position and extent of the lesion 
we distinguish cases that involve a considerable vertical area as " dif- 
fuse," those affecting whole transverse area as "transverse" and those 
with or due to crushing or direct traumatic solution of continuity 
disseminated foci. 

COMPRESSION MYELITIS.— This type is associated with trau- 
matism, spinal caries, aneurism, new growths and parasites, more 
rarely with large syphilitic growths. 

Diagnosis. — The diagnosis depends somewhat upon the recognition 
of an antecedent caries, aneurism, malignant growth or syphilitic infec- 
tion. This form of myelitis is as a rule much more painful than acute 
myelitis and in malignant disease especially most excruciating suffering 
may be witnessed from compression of the nerve roots, either directly 
by the bones, a tumor, or an exudate. In unilateral compression the 
Brown-Sequard's syndrome (p. 526) may be evident. Paraplegia in 
these cases is usually slow in development and preceded by weak- 
ness and paresthesia, the girdle sensation is usually marked and sensa- 
tion persists longer than motion. If the cord be involved above the 
lumbar region, the paralysis is spastic with exaggerated reflexes; if 
below, the reflexes are usually diminished or lost and the sphincters 
involved. Recovery may be complete in cases of pressure due to de- 
formity if the latter be corrected. 

ACUTE MYELITIS. — An inflammation of the cord substance 
may follow or more rarely directly complicate acute infectious dis- 
eases, chief of which are variola, severe dysentery and acute intes- 
tinal toxaemia, diphtheria, typhus, acute rheumatism, measles, sep- 
ticaemia and pyaemia, gummatous or endarteritic syphilis. Less impor- 
tant are erysipelas, pneumonia, malaria, puerperal fever, scarlatina 
and influenza and certain acute chronic intoxications such as alco- 
holic and gas poisoning and gout. Traumatism, with or without frac- 



ACUTE TRANSVERSE MYELITIS. 



597 



tures (sometimes mere concussion, violent torsion or flexion), caries, 
and not infrequently a combination of fatigue and exposure to wet 
and cold may initiate an attack. It may also be due to the exten- 
sion of meningitis or even neuritis, or develop secondarily in tuber- 
culosis and syphilitic processes and it occurs chiefly in men and 
between the ages of 20 and 40. 

Symptoms. — Premonitory malaise, sense of weakness and numbness, 
chill or chilliness and a variable degree of fever accompany the attack . One 
must first diagnosticate a myelitis, secondly, determine the position and ex- 
tent of the lesion: and finally, determine the probable cause as a factor in 
prognosis. The essential symptoms are, (a). Hyperesthesia,' absence of 
reflexes and a girdle pain (painful constriction) at the level of the lesion. 

\ (b). Rapidly developing, not immediate, motor paralysis below the lesion 
chiefly affecting the flexors level, partial or complete, according to the 
degree of transverse involvement, (c). Increased reflexes below the 
lesion, (d). Involvement of the sphincters, rectal and vesical, (e). 
Vaso-motor phenomena, i.e. congestion, sweating, (f). Trophic changes, 
especially pressure necrosis over the heel, hips and other dependent 
portions, (g). Changes in muscle tonus, nutrition and electrical re- 
sponse varying with the level of the lesion. The actual level of the 
lesion is best indicated by the upper margin of anaesthesia, the hyper- 
aesthetic level being just above it. It will be seen at once that the 
region involved markedly affects the motor symptoms. If in the lumbar 
enlargement the paralysis is typically flaccid, with atrophy, loss of knee 
jerks, R.D. and urinary incontinence. If mid-dorsal or cervical the 
paralysis is spastic and the reflexes are usually lost only in the areas 
corresponding to the actual level of the lesion. The picture being ordi- 
narily that of spastic paraplegia with retention of urine, increased muscle 

1 tonus, Babinski's sign, ankle clonus and patellar reflex. In the cen'ica! 

rfortn, flaccid paralysis may be marked and relatively extensive at the 
level of cord involvement and if the 4/// cervical roots be involved death 
may residt from paralysis of the diaphragm, and vomiting, bradycardia. 
syncope, hiccough and dyspmva may occur. Disseminated foci must be 
recognized by regional diagnosis. The upper level of a transverse or 
diffuse lesion is clearly indicated by the girdle pain and zone of hyper- 
esthesia, which may be emphasized by passing a hot cloth or sponge 
iVer the spine. Optic neuritis and myosis may occur in cervical 
myelitis. Symptoms of irritation (spasm or convulsions, pain) if pres- 
ent are usually of short duration, but the diseased area tends to 
JXtend. // diffuse there is acute ascending paralysis. 

39 



Sex and 
age. 



Premoni 
tory. 



Localizing. 



Ordinary 
type. 



Lumbar 
type. 



Mid-dorsal. 



Flaccid 

paralysis at 
lesion level. 



I pper 

boundary 

/one. 



Unusual 
signs. 



598 



MEDICAL DIAGNOSIS. 



Hemor- 
rhage and 
meningitis. 



Hysteria. 



Landry's 
paralysis. 



Neuritis. 



Poliomye- 
litis. 



Subacute 
and chronic 

myelitis. 



Compres- 
sion mye- 
litis. 



Anesthesia 
dolorosa. 



Brown- 
Sequard 
syndrome 
common. 



Differential Diagnosis. — Hemorrhage into the cord is characterized 
by absolute suddenness of onset, and frequently lacks fever. Abscess, 
by suppurative foci; in meningitis the irritative, painful and spasmodic 
symptoms predominate, increasing with disease duration until stupor 
or coma supervenes, whereas in myelitis they are relatively slight or of 
brief duration. The diseases may of course co-exist. Only a dorsal 
myelitis could be confounded with hysteria, and here girdle sensation, 
sphincteric involvement, true ankle clonus with perhaps extension 
spasm and the trophic changes are distinctive." In Landry's paralysis 
the lesion is an ascending motor paralysis, flaccid throughout, 
with normal electrical reactions, lost reflexes, and usually, good sphinc- 
teric control. Multiple neuritis presents at times great difficulty, but 
ordinarily the more gradual onset of paralysis, marked pain and local 
tenderness over peripheral nerve areas, and the less frequent sphincteric 
disturbance makes the diagnosis clear. The combined cases offer more 
difficulty. Acute Anterior Poliomyelitis. This shows flaccid paralysis 
throughout, seldom involves the sphincters, and lacks the gi die pain 
and other sensory and trophic phenomena of myelitis. Subacute Mye- 
litis. Differs from the acute only in its gradual onset (3-6 weeks). 

Primary Chronic Myelitis. The only essential factors are its 
slow and irregular development, affecting at random the different cord 
functions, motor, sensory and trophic, but lacking the nerve root symp- 
toms of compression myelitis. Compression Myelitis. Is suggested by 
the history or presence of spinal caries, traumatism or new growths, aneu- 
risms, syphilis, echinococcus or cysticercus cysts or syphilitic infection, 
combined with the symptoms of a slowly developing myelitis, persistent 
and perhaps agonizing pain if the nerve roots be involved (malignant 
growths and metastatic cancer causing the most severe type), and such 
pain may be marked over areas ancesthetic to painful and thermic stimuli 
(anaesthesia dolorosa). The relation of pain to spinal flexion may be i 
suggestive, as is its relief in properly treated cases of caries and deformity. 
Aside from the areas directly involved spastic motor paralysis pre- 
dominates, save in the lumbar region, and sensory paralysis varies with I 
the transverse area of the lesion. The Brown-Sequard syndrome 
may of course be present, indicating unilateral involvement. This j 
symptom complex is more common here than in any other spinal cord I 
lesion save haematomyelia. 

Course. — As any region, grade or type may be involved, the course 
varies from early death to complete recovery or the establishment of 
chronic myelitis and permanent deformities. Sensation, last to go, 



LANDRY'S PARALYSIS. 



599 



is first to return. In unfavorable cases bed sores may hasten the end, 
sometimes being associated with hyperpyrexia; descending and ascend- 
ing sclerosis may occur; the legs may become rigid or the seat of flexor 
or extensor spasm (i.e. "jackknife rigidity"), and the reflex responses 
extreme. Urinary decomposition may produce cystitis or pyelitis and 
hasten the end. It shonld be remembered that cases of slow onset and a 
I history of antecedent acute infectious disease yield the best prognosis. Bed 
' sores, high degrees of ancesthesia, sudden severe onset and an unusual 
degree of early pain and spasm are bad omens. Good habits, relative 
youth, a vigorous physique, and an absence of tuberculous or malignant 
| disease are encouraging. In chronic cases after two years no hope of 
i recovery may be entertained. 

LANDRY'S PARALYSIS.— This rare disease of unknown causation 
chiefly affects young adult males and is characterized by a progressive 
P ascending paralysis, and a sudden onset suggesting an acute infection 
■ or toxaemia. Symptoms.— .4 sharply febrile onset is succeeded by a 
complete paralysis beginning in the legs and involving in a few days or 
even hours the trunk, upper extremity, muscles of respiration and usually 
of deglutition and articulation. Enlargement of the spleen may be 
noted, the sphincters are usually not involved, the reflexes are lost, but i 
!' sensation is ordinarily preserved, or but slightly affected and the muscles do j 
f not atrophy or show abnormal electrical reactions unless ailment is of \ 
I unusually long duration. Prognosis.— Death in from 48 hours to two 
j weeks is the almost invariable result* Nothing definite can be said of 
1 the pathologic changes save that the lower motor neurones are the point 
I' of attack. Acute myelitis shows anaesthesia, bed sores, reaction of de- 
' generation and atrophy at the level of the lesion and early involvement 
rof sphincters. Multiple neuritis cannot be positively differentiated in 
j' certain rare instances (see multiple neuritis). 

POLIOMYELITIS ANTERIOR ACUTA.— (Acute anterior polio- 
i' myelitis). Etiology and Morbid Anatomy.— This acute and 
destructive disease is probably due to primary thrombus or embolus 
involving the arterial supply and hence the nutrition of the motor cells 
of the anterior horns, with occasional slight meningeal involvement; 
hemorrhagic myelitis followed by atrophy being the essential change. In 
j long standing cases the dependent anterior nerve roots degenerate, and 
atrophy of the muscles and the react ion of degeneration follow in a few 

•The author kept a young girl alive for 41 days by artificial respiration 
breathing having ceased early in the attack. Muscle atrophy was well 
marked in later stages 



Determin- 
ing factors. 



Chronic. 



Rarely de- 
scending 
not afebrile. 



Sensation 
preserved. 

Sphincters 
rarely in- 
volved. 

Atrophv 
and R. D. 

usually- 
absent. 



L 



6oo 



MEDICAL DIAGNOSIS. 



Children 
chiefly. 

Occasion- 
ally epi- 
demic. 



Variable 
onset. 



Flaccid 
paralysis. 



Distribu- 
tion. 



Atrophy, 
lost knee 
jerks and 
R. D. 



Usually . 

permanent 

disability. 



Adult 
males. 
Usual 
factors. 

Motor 
neurone de- 
generation. 



/lays the sudden onset of paralysis. Children under three years of age 
are chiefly affected, sometimes when in perfect health or, after some in- 
fectious fever, and occasionally it assumes an epidemic form. Adults 
are seldom attacked, but if so the symptoms are identical with those 
to be described. 

Symptomatology. — The onset is variable; in certain cases the 
paralysis is unconnected with any definite febrile attack ; more commonly 
there is slight transient fever and malaise, while rarely, high fever, diar 
rhcea, vomiting, delirium, convulsions and coma may be present. The 
more severe the primary attack the more rapid is the onset of paralysis. 
Pain and tenderness in the affected limbs may first attract attention 
but are usually absent or unimportant. The paralysis may involve all 
four extremities, rarely one, more usually both legs and especially the 
peroneal and tibial groups, and tends to recede in certain muscle groups 
and become marked and permanent in others. Whenever a large 
muscle tract is involved great inequality of damage is evident and 
certain muscles such as the forearm extensors are almost immune. 
Secondary contractures occur late in the disease. It should be remem- 
bered that the onset of this disease is sudden, the paralysis appears 
within from 24 to 48 hours, the lesions soon become fixed, the paralysis 
is flaccid, atrophy rapid and extreme, reflexes and normal electrical re- 
actions lost, sensatim unaffected, and, that the sphincters and facial 
muscles are rarely involved. 

Prognosis. — Seldom fatal, the disease is nevertheless a terrible one 
by reason of the persistence of the paralysis. I* 1 certain cases, due 
evidently to toxaemia, brisk and persistent eliminative treatment may 
result in complete or partial recovery. Rarely a recoverable case of 
neuritis may present almost identical symptoms. 

PROGRESSIVE MUSCULAR ATROPHY.— (Amyotrophic lat- 
eral sclerosis), (chronic anterior poliomyelitis), (progressive bulbar 
paralysis). This is a disease of unknown causation, affecting chiefly 
adult males beyond the age of 30, said to be influenced etiologically 
by the usual factors, such as traumatism, excessive mental or physical 
strain, exposure to wet or to cold, and, to a slight degree, hereditary 
influence. 77 is essentially a gradual degeneration of the motor neurones, 
either lower or upper being first involved, the lower in the greater degree. 
The degenerative process affects the gray matter of the anterior horns 
and fibres of the anterior nerve roots within and without the cord, and, 
the intermuscular branches. The degeneration of the gray matter 
extends to the medulla and the antero-lateral white tracts and lateral 



PROGRESSIVE MUSCULAR ATROPHY. 



60 1 



pyramidal tracts are affected in varying degree, in some cases even to 
the motor cortex. There is of course marked muscular atrophy. 

Symptoms of the Aran-Duchenne Type. — Following a period 
of vague and indefinite pseudo -rheumatic pain, muscular atrophies ap- 
pear in the following order. The muscles of the ball of the thumb (the 
patient first noticing an inability to adduct the thumb, separate the 
index from the middle finger, write, or button his clothes), the inter - 
ossei and lumbricales, forearm flexors and extensors and the deltoid, fol- 
lowed by other muscles of the shoulder girdle group. One hand is 
usually first affected and the muscles of the legs and face and the 
trapezius are usually attacked late. The platysma myoides entirely 
escapes and indeed may hypertrophy and fibrillary contraction is marked. 
The atrophy of the muscles of the hand and forearm produces the so- 
called u claw hand" and the wasting of intercostal and abdominal mus- 
cles reduces the patient to a helpless skeleton. Later the neck and 
even in some instances those of the face are involved and in prolonged 
cases those of the legs. The electric excitability of the muscles is early 
diminished and finally lost, the reaction of degeneration occurring in rap- 
idly advancing cases. Muscular power of course disappears pari passu 
with the wasting. Subjective sensory symptoms may be present yet sen- 
sation is unimpaired and the sphincters unaffected, but the knee jerks 
are lost when the quadriceps extensor atrophies. 

Amyotrophic Lateral Sclerosis. — In certain cases of a pro- 
gressive muscular atrophy described as amyotrophic lateral sclerosis 
a primarily spastic paralysis is associated with atrophy following the 
Aran-Duchenne order quite closely. In these the reflexes are increased 
and the picture is one of spastic paraplegia with the typical gait but 
with gradual atrophy. Jaw clonus and Babinski's sign are present 
but the sphincters are unaffected. The tendon reflexes are seldom 
increased in the flaccid type, markedly increased in the amyotrophic 
type. Fibrillary contraction is marked and there is a generally exag- 
gerated motor response to muscle or tendon percussion, yet there is 
usually a partial reaction of degeneration. Bulbar involvement is 
often early and may precede the leg involvement. 

The Bulbar Type. — (Glosso-labio-laryngeal paralysis). Bulbar 
symptoms may precede or follow spinal symptoms but no actual patho- 
logical distinction exists to justify making of the primary bulbar type 
a separate disease. Bulbar involvement is indicated by difficulty in 
the pronunciation of the Unguals and denials, atrophy and weak' 
the tongue leading to dysphagia, dysarthyria, the accumulation oi saliva 



Order of 

involve- 
ment. 



Fibrillary 
.contrac- 
tions. 

Trapezius 
late. 



Platysma 
not at all. 



Knee jerks 
long re- 
tained. 
Sensation 
unaffected. 



A blend of 

anterior 
polio- 
myelitis. 

spastic 

paralysis 
and bulbar 
palsy. 



Fibrillar? 
tion. 



6o2 



MEDICAL DIAGNOSIS. 



Acute bul- 
bar form. 



Peroneal 

ascending 

form. 



Fibrillary 
contrac- 
tion. 



and drooling. With involvement of the lips, labial pronunciation 
becomes difficult and succeeding paralyses of the pharyngeal and laryn- 
geal muscles increase the dysphagia and enfeeble the voice. This type 
may be associated with progressive atrophy of either the tonic or flaccid 
type and cases of acute onset occasionally occur. A similar condition 
affecting the eye muscles is known as progressive ophthalmoplegia. 

Muscular Atrophy of the Peroneal Type. — This differs from 
the preceding form in three particulars, -first, that it is an hereditary 
or family disease. Second, in that the atrophy commences in the muscles 
of the feet and peroneal group, often unilaterally at first, this being the 
reverse of the usual form. Third. Sensory disturbances are promi- 
nent; it especially affects young children, and leads to various forms of 
club foot and the sphincters are not involved. 

Differential Diagnosis. — The chief difficulty arises in distinguishing 
between a progressive muscular atrophy of the spastic type and syrin- 
gomyelia, differentiation being only possible when the peculiar retained 
general sensation with sensory symptoms of the latter disease are 
pronounced. The bulbar type must be distinguished from the pseudo- 
bulbar palsy of cortical origin which results from bilateral lesions in 
the facial area of the cortex or between these areas and the cranial 
nuclei, which lacks the fibrillary tremor, rapidly advancing atrophy and 
R. D. of bulbar palsy. 

MUSCULAR DYSTROPHIES.— There are various clinical forms 
of muscular wasting, with or without initial hypertrophy, classed under 
diseases of the nervous system but lacking definite pathologic findings. 
Atrophy, palsy and marked hereditary tendency usually co-exist in all 
forms. 

Etiology. — The disease may exist in a family for generations and is 
most frequent in the male. Atavism similar to that of haemophilia 
is evident, the mother transmitting the disease even though herself 
unaffected. 

Classification. — No sharp dividing line can be drawn, but for clin- 
ical purposes cases may be divided into (a) those occurring in youths 
and adults, (b) those of childhood. Class (a). The disease may assume 
one, atrophic and two, hypertrophic forms. The former including 
(a) cases without involvement of the facial muscles, (b) those in which 
they are early involved. The latter includes both cases of genuine 
hypertrophy, and those of muscle lipomatosis. 

PSEUDO-MUSCULAR HYPERTROPHY.— Symptoms.— Mo- 
tor impairment calls attention to apparent enlargement of the muscles usu- 



No pa- 
thology. 



Heredity. 



Two 
classes. 



PSEUD O -MUSCULAR HYPERTROPHY. 



603 



Prominent 
weak 

muscles. 



A lifting 
test. 

Terminal 
stage. 



ally first of the calves. The leg extensors, glutei, the lumbar muscles, 
the deltoid, the triceps and infraspinatus are excessively involved and 
become prominent and resistant yet weakness co-exists and is progressive. 
Placed upon the floor the patient passes through a succession of char- 
acteristic movements to regain a correct posture. (See fig. 230.) When Posture, 
standing there is lordosis, the shoulders are thrown back, belly prom- 
inent and feet widely separated. The shoulder 
girdle being greatly weakened and extremely 
movable makes the arms abnormally long and 
yields a sensation of slipping if an attempt is 
made to raise the child by catching him under the 
armpits. The terminal picture is that of extreme 
atrophy and helplessness without fibrillary twitch- 
ing or R.D. but associated with mental degener- 
ation. 

Duration of the disease is from a year to two 
decades or more, death occurring from intercur- 
rent disease or inanition, and prolonged remis- 
sions may occur. 

Differential Diagnosis of Muscular Atro- 
phies.— The chief difficulty in diagnosis arises 
in differentiating between certain cases of the 
disease which present overlapping symptoms, it 
being sometimes impossible to assign a case 
definitely to a single division. It should be 
remembered that in the pseudo-muscular hyper- 
trophy the typical symptoms as just described 
are present, whereas in the facial type the first Pacini typo 
changes appear in the muscles of the face, particu- 
larly the orbicidaris oris and extend to the muscles 
of the cheeks and forehead, affecting both expres- 
sion and speech and producing what is known 
as the tapir mouth. The extension to the general 
muscular system is downward. Erb's juvenile 
muscular dystrophy is characterized by its being 
youth, having its incidence usually at the 




ig. 230.— Characteris- 
tic postural changes in 
pseudohypertrophic pa- 
ralysis accompanying act 

of rising from floor. 

(After Gowers and Starr.) 



Erb 



distinctly a disease of 
puberty and within the age limit of 12 and 20 years (] 2 10 usually). 
Furthermore (hat the muscles first involved are those of the shoulder 
girdle. In all forms late contractures are of course common with the 
usual deformities. Fibrillary contraction of muscle, reaction of degener- 



604 



MEDICAL DIAGNOSIS. 



Peculiar 
complex. 



Erb's myo- 
tonic re- 
action. 



Simulates 

bulbar 

paralysis. 



ation, disturbance of sensation and reflexes are lacking until extreme 
atrophy and weakness have developed. 

DISEASES OF THE MUSCLES. 

MYOTONIA. — (Thomsen's disease). This is a disease of childhood, 
of the family and hereditary type, affecting chiefly the male, and very 
rare in this country. Occasionally cases of the acquired type may 
be encountered. 

Symptoms. — The characteristic symptom is a peculiar slowness of 
muscular contraction and relaxation, most marked in prehension and 
locomotion. The hand closes slowly and awkwardly around the object, 
and relaxation is equally deliberate. So in walking the leg is slowly 
advanced and halts for a second or two, yet the awkward gait lasts 
for but a few steps. The laryngeal, ocular and facial muscles are rarely 
affected, the general musculature is well or unusually developed and 
out of proportion to the actual strength. As might be expected the 
electrical reaction of the involved muscles is deliberate and asso- 
ciated with vermicular contractions between the poles. The disease is 
essentially chronic and incurable. 

MYASTHENIA GRAVIS.— (Asthenic bulbar paralysis. Erb-Gold- 
flam's syndrome). This is a progressive loss of muscular power associ- 
ated with rapid exhaustion under faradic stimulation though not under 
galvanic (Jolly's myasthenic reaction). The loss of power affects first the 
muscles of the eye, face, jaws and neck, but may involve the entire body. 
The essential symptom is the rapid fatigue of the affected muscles, 
restored by rest, and this in connection with the peculiar electric reac- 
tion, the transient nature of the symptoms, simulating paralysis, and 
the absence of true atrophy or fibrillary contractions makes the diag- 
nosis easy. The disease is essentially chronic, but the mortality prob- 
ably exceeds 30%. 

MYOSITIS. — This condition may be suppurative or non-suppurative 
and represents an actual inflammation of the voluntary muscles. The 
symptoms are those of localized inflammation involving the muscles 
in a variable degree. They may feel doughy or in other instances 
hard, are tender and there may be slight edema of the skin 
overlying them or of the extremities involved. The diagnosis from 
trichinosis is only to be made by examination of the muscle fragments, 
though recent observations strengthen the assumption that trichinosis 
is usually associated with eosinophilia. 

MYOSITIS OSSIFICANS PROGRESSIVE.— This begins with an 



NEURITIS. 



605 



apparent cervical myositis which recedes and is "followed by progres- 
sive induration and ossification, which may involve nearly the entire 
musculature. The disease is excessively rare and chronic. 

Paramyclonus Multiplex. — See p. 32. 

NEURITIS. — Inflammation of the nerves may be single or multiple 
and due to toxaemia, extension of inflammation, actual germ invasion 
(leprosy), traumatism involving wounds, tears, concussion and torsion, 
pressure, and finally, to cold. The toxaemias, whether due to mineral 
poisoning or acute and chronic infections are often associated with 
polyneuritis, the acute infectious diseases most frequently observed 
being diphtheria, erysipelas and leprosy, and of minerals, lead, arsenic 
and mercury. Beriberi is an acute infectious disease of which poly- 
neuritis is the predominant and characteristic symptom. Fatigue 
associated with chilling or prolonged exposure to cold and wet is a 
common cause of both local and polyneuritis; alcohol is also a potent 
cause. 

Symptoms. — Whether the neuritis be local or general, the symptoms 
are essentially the same, the differences being those of anatomic distri- 
bution. Pain is severe, persistent, boring or stabbing, and is asso- 
ciated with tenderness on pressure. It is usually most marked at the 
terminal points, but may be felt along the whole course of the nerve. 
Edema and congestion may be present over the same area, muscular 
power is impaired, motion is painful. Tactile sense is impaired or 
lost, formication and numbness are common, and actual paralysis follows, 
as does muscular atrophy, the skin becoming shiny, and the nails brittle 
and deformed. Where the larger trunks are involved the reflexes may 
be lost and the paralysis be typically flaccid. It must be remembered 
that all degrees of inflammation are encountered as is illustrated by the 
behavior of the muscles in relation to the electric current. In some 
cases reaction of degeneration is complete and prompt, in others the 
response is normal. 

ACUTE FEBRILE POLYNEURITIS.— This is merely a multiple 
neuritis characterized by an acute febrile onset exactly simulating that 
of the acute infectious diseases, the temperature being high as a rule. 
Subsequently a typical neuritis symptom complex develops taking the 
form usually of an ascending paralysis of varying degree, most often 
commencing in the feet, less often in the arms. // may be limited to 
the extremities or affect the -whole body even to the involvement oj lite dia- 
phragm and other respiratory museles. Heath is common in the severe 
forms, but as a rule the patient recovers ajter an illness of a month 



Infection, 
toxaemia, 
trauma- 
tism. 



Fatigue 
and chilling 
Alcohol. 



Pain. 



Tender- 
ness. 



Paresis. 
Sensory 
disturb- 
ances. 

Trophic 
changes 
ami re- 
Rexes, 

k. n. 



Multiple 
neuritis. 



Ascending 

p.u a'\ SIS 

ibu- 

lion. 




6o6 



MEDICAL DIAGNOSIS. 



Foot and 
wrist drop. 
Prancing 
gait, in 
peroneal 
type. 

Localiza- 
tion. 



Baron 
Takaki's 
great work. 



Mild, wet, 
dry and 
pernicious 
forms. 



Diagnosis. 



weeks. Residual partial paralyses are frequent, but seldom persist for 
more than a year. 

Neuritis due to Alcohol, Lead or Arsenic. — In this form the 
onset is usually gradual and preceded by numbness, tingling and neuralgic 
pain. "Foot drop" and "wrist drop" are common features, giving 
rise in the former case to the prancing or steppage gait. In alcoholic 
cases mental symptoms may be present, but the history of the case usually 
I points the way to a correct etiologic diagnosis, and it should be remem- 
| bered that these paralyses chiefly affect the extremities, and that 
diphtheria shows a preference for the muscles of the eye and throat, 
lead for the extensors of the arms, arsenic for the legs and expecially 
the peroneal group. The distinctions are of course often disregarded. 

Beriberi. — This peculiar endemic epidemic neuritis causes a large 
mortality in Asiatic countries, is especially prevalent in the Malay 
Archipelago and a few important cases are encountered in this country 
usually from South American and West Indian ports or among fisher- 
men on the Newfoundland banks. The cause is unknown, but the 
Japanese Surgeon -General has found that a marked diminution in the 
incidence of the disease follows the withdrawal of raw fish from the 
diet, and the substitution of unshelled for shelled rice. General hygiene 
undoubtedly plays an important part.* 

Symptoms. — The symptoms are chiefly those of neuritis of greater 
or less severity. Edema is an important symptom varying from 
that of the slightest degree to a general anasarca. Palpitation and 
dyspnoea are also marked symptoms varying greatly in severity. A 
somewhat arbitrary classification is based upon the factors above named, 
there being a "mild form," in which all symptoms are slight, a "wet 
or dropsical" variety in which edema is the predominant symptom, 
the "dry form" characterized by predominant paralysis and relatively 
slight edema and the "pernicious form" in which cardiac symptoms 
predominate. The diagnosis therefore depends upon the association of 
multiple neuritis with edema or marked cardiac disturbance in connec- 
tion with the known prevalence of the disease, or the past residence, or 
associations of isolated cases. 

Recurrent Multiple Neuritis. — It would hardly seem that a sep- 
arate place should at present be given to a polyneuritis showing a 
marked tendency to recurrence. 

* Baron Takaki, in a recent conversation stated to the author that the 
mortality and incidence in the fighting forces had been reduced to an almost 
negligible factor. 



HERPES ZOSTER. 



607 



Pressure Paralysis. — It is hardly necessary to do more than call 
attention to the various paralyses due to compression of individual 
nerve trunks. The common wrist drop of musculo -spiral paralysis and 
circumflex paralysis resulting from dislocation of the humerus are the 
most common. The former may result from crutch pressure, or pres- 
sure during deep sleep, especially "in the open" or may result from 
the position in which a patient is placed during a long operative pro- 
cedure. (See also brachial plexus paralysis.) 

General Points in the Diagnosis of Neuritis. — Pain, tenderness 
on pressure over nerves, muscular weakness or paralysis, atrophy, early, 
though variable R. D., trophic disturbances and impaired tactile sensation 
following definite and known anatomic paths make the diagnosis of neuri- 
tis. Complete paralysis is necessarily of the flaccid type, though irritative 
symptoms in the form 0} localized twitching and spasm may be associated 
with a normal or partial electrical response; the steppage gait is charac- 
teristic of certain forms, inco -ordination, pupillary symptoms and lighten- 
ing pains, absent; alcoholic and lead neuritis are usually made evident 
by the history and occupation, foot and wrist drop; and perhaps, delir- 
ium, and in arsenical cases there is often a yellow skin. 

Von Recklinghausen's Disease. — This interesting condition is 
characterized by a generalized neuro-fibromatosis, producing a remark- 
able variety of pressure symptoms referred to all parts of the body, 
patchy pigmentation of the skin and marked impairment of intellection. 

NEURALGIA.— See "pain" p. 68. 

HERPES ZOSTER.— (Zona), (shingles). This disease is char- 
acterized by violent neuralgic pain along the course of the superficial 
cervical, thoracic, sacral or abdominal nerves, or the branches from the 
Gasserian ganglion, associated with the appearance of crops of vesicles 
corresponding to the superficial nerve distribution and has its commonest 
seat over the lower thoracic of upper abdominal zone. It is commonly 
unilateral, but may be bilateral and is supposed to be due to an 
inflammation of the ganglion cells of the posterior roots. There is 
no disease which causes more exquisite pain and suffering, usually oj 
a few days' duration, but sometimes extending over long periods, and 
furthermore, troublesome ulceration may follow rupture and coales- 
cence of the vesicles. The excessive severity and distinctly neuralgic 
or neurotic type of the pain and its distribution, and the typical rash 
makes the diagnosis clear, but the pain may precede the Iter pes by 
hours or even days and prove misleading, especially in the thoracic form. 

PERIODIC TRANSIENT PARALYSIS. This curious ailment 



Dislocation 
and crutch 
palsies. 



Localizing 
features 
often strik- 



A curious 
syndrome. 



Usually 

thoracic 
and un- 
ilateral. 



Extreme 

pain. 



herpes 



6o8 



MEDICAL DIAGNOSIS. 



Recurrent, 
afebrile, 
transient 
paralyses. 



Prognosis. 



Hiemal. 



Three 
forms. 



Exciting 
causes. 

Lividity. 
Gangrene. 



Sensation. 



Necrosis 
limited. 



Occasional 
symptoms. 



is strikingly hereditary, often traversing five or six generations, and is 
characterized by the rapid onset of paralysis involving the arms and legs, 
or both, sparing the face, though sometimes implicating the regions sup- 
plied by the vagus and spinal accessory. There is no fever, a slow 
pulse, general diminution, but rarely a loss of reflexes, deep or super- 
ficial, and, marked diminution of faradic excitability. These paralyses 
are transient, lasting for only a few hours as a rule, but are strikingly 
recurrent and periodic, diurnal cases being noted. Like migraine the 
periodic paralysis usually ceases at the age of 50. 

RAYNAUD'S DISEASE.— (Symmetrical gangrene, local asphyxia). 
This mysterious hiemal vaso-motor affection of unknown causation 
assumes three forms, (1) local asphyxia, (2) local syncope, (3) symmet- 
rical gangrene. Local asphyxia and local syncope in their mildest 
form may be seen in chilblains. In Raynaud's disease either emotion 
or trivial exposure to cold, or even gastric disorders are followed by 
coldness, pallor of the surface of the fingers or of both fingers and toes. 
After a variable period and in irregular order the affected members 
become sharply congested and perhaps livid. Stiffness and discomfort 
or even severe pain may accompany the swelling. Symmetrical gangrene 
varies greatly in degree, is rarely extensive, and usually a persistence 
of the extreme stagnation of the cyanotic stage results in superficial 
necrosis involving small areas or oftentimes but one finger or toe. Sen- 
sation, often diminished in the cyanotic stage, is lost over the gangrenous 
area which is black, icy cold and covered with blebs. The area of 
apparent involvement greatly exceeds that of actual necrosis. The ear 
is involved frequently, the tip of the nose occasionally, symmetrical 
areas on the arms, legs or trunk rarely. Cases of rapid, extensive and 
fatal gangrene have been reported and occur most often in children. 
Aside from the local symptoms there are no constant disturbances. 
Hemoglobinuria, transient loss of consciousness, mental torpor and 
delirium are occasionally observed.* 

Diagnosis. — The diagnosis, of course, depends upon the occurrence 
of symmetric localized syncope, cyanosis or gangrene without an assign- 
able organic cause. 

* In one case observed by the author symmetrical gangrene of the ears 
of the hiemal type had resisted treatment for years, but recovered promptly 
when the cause was found. The patient was taking large quantities of 
morphine by the hypodermic method, the skin over large areas of the trunk 
and limbs being thickened and infiltrated through the use of a dirty 
syringe. As withdrawal was resisted the patient was told to take the drug 
by the mouth, since that time (14 years) there has been no recurrence of 
the gangrene. 



ERYTHROMELALGIA. 



609 



One of the 
four bas- 
tard syn- 
dromes. 



Subjective. 



ERYTHROMELALGIA.— This rare condition unlike Raynaud's 
disease is essentially a summer ailment and is characterized by super- 
ficial congestion, swelling and burning pain in the feet or hands usually 
the former, and worse at night, the pain being severe and increased 
by the dependent position. It is chronic and irregularly recurrent, 
often associated with headache and vertigo, and occasionally with 
Raynaud's disease. 

ACROPARESTHESIA— This symptom complex is closely allied 
to angio-neurotic edema and is characterized by itching, burning, prick- 
ling and pain in the fingers and toes. Heat, cold and injury are appar- 
ently causative factors; constipation and gastric disorders almost con- 
stant, and occasionally there is rigidity of the fingers. It is hardly 
worth separate classification. 

INTERMITTENT JOINT EFFUSIONS.— Closely allied to angio- 
neurotic edema is this rapidly produced but painless swelling of the 
joints. It lasts for only a few days, but is liable to recur. 

ANGIO-NEUROTIC EDEMA.— This vaso-motor condition seems 
closely related to urticaria and, like it, is usually associated with diges- 
tive disturbances. Exposure to cold and emotion may be associated 
with it, but it often appears without apparent cause. It is essentially 
a sudden and transient swelling, affecting usually the hands, feet, genitalia, 
or any portion of the face, rarely the lips, tongue or even the glottis where 
it may produce dangerous or fatal obstruction. As in Raynaud's 
disease associated haemoglobinuria has been noted. It may be periodic 
but is more often irregularly recurrent. The gastro -intestinal symptoms 
may be severe and associated with vomiting and colic, or, extremely 
slight. Osier reports a case in which the whole arm was swollen. 
Aside from the rare involvement of the glottis the disease is as unim- 
portant as it is obscure. 

FACIAL HEMIATROPHY.— This incurable and obscure condi- 
tion, most frequently developed in childhood, rarely in the adult, is a 
progressive atrophy involving all structures on one side of the face. It 
is peculiar in that it affects first the skin and superficial tissues, thou 
the bone and lastly the muscles. Loss of the hair and teeth and hem- 
iatrophy of the tongue and palate usually occur, but bilateral atrophy 
is rare and sensation and the electric response o\ the muscles is usu- 
ally unaffected. It is probably not due to disease oi the trigeminus 
and as is generally held should not he confounded with congenital 
asymmetry of the face. In direct contrast is unilateral facial hyper 
trophy in which every Symptom is reversed. 



Usually 
trivial. 



Occasion- 
ally seriou; 



Peculiar 

line ol 
march. 



6io 



MEDICAL DIAGNOSIS. 



Alterna- 
tives in 
heredity. 

Exciting 
causes. 

Age. 



Senile 
cases. 



Aurse. 



Onset. 
Seizure. 



EPILEPSY. — This psychoneurosis depends to an extraordinary de- 
gree upon heredity, but in predisposed individuals may apparently arise 
from emotional shock, acute toxaemias and sometimes from remote and 
purely reflex causes. One variety arises from direct irritation due to 
injury, recent or remote, or forceps injuries in childbirth, and one- 
half the cases occur in the first five years of life. It is so rarely a primary 
\ lesion in the adult as always to excite a suspicion of organic disease. Sex. 
The incidence is nearly equal in the two sexes. Of inheritance it should 
further be said that it is not so much direct as equivalent (see page 47) . 
Parental intemperance, for example, is an important factor, syphilis 
and alcoholism common and direct causes. Attacks very similar 
to true epilepsy occur in arteriosclerosis, which condition probably 
accounts for the cases met with in old people. 

Divisions. — We speak of "major epilepsy" (grand mal), "minor 
epilepsy" (petit mal), "Jacksonian epilepsy" and, "psychical epileptic 
equivalents." 

Grand Mal. — Aurce and various subjective sensations precede an 
attack. There may be auditory, visual, gustatory and olfactory pares- 
thesias, discomfort in the epigastrium, intestines or rectum, or peripheral 
sensations usually referred to the hand. In other cases the aura is 
motor, the patient turning rapidly, running for a short distance or twirling 
about on the toes. The actual onset is sudden, sometimes preceded 
by the so-called epileptic cry. A fall is likely to produce injury, a 
matter of importance in differentiating hysteria, and, the condition is 
one primarily of tonic spasm, the patient being livid and usually in a 
distorted attitude; after a few seconds follows the stage of clonic con- 
vulsions, at first slight, but increasing rapidly in violence and affecting the 
ocular and facial muscles as well as those of the body and ex'remities. 
The patient froths at the mouth, is likely to bite the tongue, or pass 
1 urine or fecal matter involuntarily. The duration of this stage is 
variable, but it seldom lasts over two or three minutes and is followed 
by coma, succeeded by a deep sleep lasting for several hours if undis- 
turbed, the patient wakening with slight mental confusion or perhaps 
headache. The attacks vary greatly in frequency, usually tending 
to increase with the lapse of time. They may occur only at night and the 
patient mav be and often is, entirely unconscious of their true nature, 
a point to be remembered in case -taking.* In the so-called "status 



Tongue 
biting. 

Inconti- 
nence. 



Coma. 



Increasing 
frequency. 



Nocturnal. 



* In one such case observed recently there was nothing to mark the at- 
tack in the morning but a slight persistent injection of the facial capillaries, 
the patient feeling perfectly well, with unclouded mind. 



EPILEPSY. 



611 



epilepticus" there is fever, rapid respiration and increased pulse rate, 
accompanying a succession of attacks without persistent unconscious- 
ness. The reflexes are sometimes absent, more often increased and 
accompanied by ankle clonus. The urine if not passed during the 
attack as is usual, is passed in quantity after it. Post-epileptic paralysis 
and aphasia are occasionally seen but are ordinarily transient. In 
repeated seizures mental deterioration may be marked and post-convulsive 
mania may assume a dangerous form and become of medico-legal impor- 
tance in murder cases. So also these unfortunates may be arrested for 
indecent exposure due merely to mental disturbances, characterized 
by various automatic actions of which the patient has no consciousness 
or recollection. 

Petit Mai. — This interesting condition lacks the convulsive features 
of epilepsy, though in a majority of instances grand mat develops, either 
wholly replacing or alternating with the minor attacks. Amongst the 
various forms may be mentioned simple incoherency, acts of automatism, 
usually of short duration, sudden falls, with or without transient loss 
of unconsciousness, sudden jerkings, tremor or subjective sensations 
of various sorts, mere interruption of conversation, and a peculiar absent 
mindedness. During such attacks the patient is likely to turn sud- 
denly pale, there may be fixation of the eyes and relaxation of the 
grasp but aurae seldom occur. 

Jacksonian Epilepsy. — This is the reverse of petit mal, conscious- 
ness being retained early in, or throughout, the attack and convulsive seiz- 
ures present. One must admit possible sensory equivalents but direct 
cerebral irritation is nearly always present. The spasms arc usually 
orderly and follow motor areas of the cerebrum, but may be limited to one 
tract such as the face and leg. Partial epilepsy, moreover, often becomes 
general with the lapse of years, old injuries, tumor, meningitis, cere- 
britis, uraemia, abscess, hemorrhage and sclerosis are the usual causes 
and post-haemiplegic epilepsy is of this type. 

Epileptic Equivalents, Psychoses. — Hallucinations of hearing, 
narcolepsy (profound sleep), and sometimes, certain cases of somnam- 
bulism, seem to replace the convulsive stage of epileptic seizures, and 
in some instances, certain moral deficiencies are also prominent, often 
amounting to an entire change of character or the development of traits 
or habits abhorrent to the patient in a condition of health. 

Differential Diagnosis. If an attack of major epilepsy he seen 
little doubt can be entertained as to its nature, though only by an i 
ifiation of the urine can unc/nic convulsions be positively </:' 



Polyuria. 



Mental 
changes. 



Spurious 

exhibition- 
ism. 

Convul- 
sions 
absent. 



Curious 
manifesta- 
tions. 



Petit mal 

reversed. 
I 

Motor 
tract 

spasms. 



Peculiar 

and im- 
portant. 



1 



6l2 



MEDICAL DIAGNOSIS. 



Uraemia 
and hys- 
teria. 



Etiology. 

Precocious 
children. 



Unwise 
parents. 

Secondary 
factors. 



Reflex 
course. 



Age and 
sex. 



Rheuma- 
tism. 



Heart 
disease. 



Hysteria offers many difficulties, but is seldom accompanied by tongue 
biting, involuntary passage of urine, and never by the absolute uncon- 
sciousness presented by the epileptic. Hysterical patients choose a safe 
place to fall and the movements are usually disorderly and to a certain 
extent purposeful and struggling rather than jerking; moreover, the 
duration of the hysterical attacks is longer and often promptly relieved 
by sharply applied pressure over the ovaries. 

Jacksonian epilepsy is unmistakable, though its cause may be obscure; 
petit mal, often beyond the range of absolute diagnosis, its recognition 
depending upon the coincidence of transient unconsciousness, vertigo, and 
perhaps automatism. 

CHOREA. — (St. Vitus's dance, Sydenham's chorea). This is a disease 
of unknown causation apparently depending largely upon an inherited 
or acquired neuropathic temperament, Precocious, imaginative, excit- 
able children are peculiarly liable to the disease, especially if, as is so 
often the case, they are pushed ahead in their studies or encouraged 
to develop any unusual mental traits at an unduly early age. Over- 
forcing is the chief cause of chorea, and the elements of shock, worry, 
grief, etc., are merely secondary factors in causation. Seizures due to 
reflex irritation are rarely seen but may occur in connection with various 
conditions affecting the gastro-intestinal tract, sexual organs and in ore 
often as a result of naso-pharyngeal adenoid growths. The disease 
predominates in females between the ages of 5 and 15, is less often seen 
in the well-to-do, and seems to bear some relation to rheumatism and a 
more direct one to heart disease* It is often difficult to decide whether 
rheumatism preceded or followed the development of the disease, and 
the same difficulty is encountered in heart disease which is by many 
believed to be the cause of chorea (the so-called embolic theory). It is 
certain that about \ of the cases show valvular murmurs, but it is by no 
means proven or even rendered probable that a resultant embolism is 
the cause of the disease. If we assume, however, a neuropathic con- 
stitution, to which is added rheumatism or a valvular heart lesion 
with its attendant disturbances of circulation, it is easy to see that 
in a sense the latter might be causative. The author believes that be- 
yond such an assumption there is no adequate basis for any of the 
present theories concerning the etiology of chorea. 

Symptoms. — Involuntary, inco -ordinate, characteristically jerky move- 
ments, unilateral or bilateral, localized or general, and associated to a 

* In Osier's analysis of 554 cases only 15 xo% showed a clear history of 
acute or subacute arthritis. 



CHOREA. 



613 



varying degree with excitability and emotional disturbances, characterize 
chorea. Though difficult to describe it is never forgotten when once 
seen, nor does it offer any difficulties to the diagnostician save in 
its rarest forms. According to its severity we recognize a mild and 
severe form, to which may be added a third, the maniacal chorea, which 
is associated with delirium. The predisposing factors have already 
been considered and the exciting causes of an attack are often of an 
emotional sort. 

Symptoms. — Premonitory symptoms take the form of increased nerv- 
ous irritability, perhaps unusual wilfulness, and a general restlessness. 
As the irregular movements begin, the apparent clumsiness of a child, 
associated perhaps with unusual disobedience, may bring about unde- 
served punishment which may precipitate the attack. The face and 
arm are most commonly involved, but in severe cases the whole body 
may participate. Disturbance of speech occurs in about one-fourth 
of the cases, varying greatly in degree and the facial grimaces and 
jerking, inco -ordinate and bizarre movements of the extremities involved 
are absolutely distinctive. If the legs be affected a peculiar jerky 
hitching gait appears, and there may be motor weakness in the leg ! 
or arm. Occasionally there is crossed chorea, still more rarely one 
encounters the most severe type, maniacal chorea. Mental disturb- 
ances of marked degree are unusual yet intervals of delirium or tempo- 
rary hallucinations sometimes occur. Practically all of the other asso- 
ciated symptoms would seem to be dependent upon rheumatism and 
endocarditis as factors. The heart symptoms are chiefly those of func- 
tional or organic murmurs, the latter being present in about 50^ 
of all cases and two-thirds showing a murmur of some sort. The 
ordinary hemic murmur with its maximum at the second pulmonary 
interspace is of little moment, and other functional murmurs may In- 
associated with the accelerated heart action almost invariably present. 
The common murmur is systolic and apical and the differentiation 
between the functional and organic lesion must depend upon the 
application of the usual diagnostic rules. Evidence of secondary dila- 
tation and the presence of a loud harsh murmur indicate an organic mitral 
lesion. Arsenical pigmentation may occur, but fever, purpura, urticaria 
and joint symptoms have probably no direct relation to the disease 
itself, but rather to the digestive disturbance and rheumatism with 
which it is so frequently complicated. 

Course. Although showing a distinct tendency to recurrence (50^ ), 
the individual attacks seldom last over two or three months, though 

-1° 



A clean-cut 

clinical 

picture. 



Varieties. 



Misunder- 
stood clum- 
siness and 
" badness." 



Speech, 
gait. 

Rare 

mental 

symptorr 



Heart 
signs. 



Murmur: 



t. utaneous 
signs. 



614 



MEDICAL DIAGNOSIS. 



Hereditary 
chorea. 



Frie- 
dreich's 
ataxia. 

Hysteria. 



rarely they may extend over years, particularly as slighter manifes- 
tations. The death rate during the attacks is almost negligible. 

Differential Diagnosis. — It should be remembered that choreiform 
movements are increased by excitement or obstruction, entirely cease 
during sleep, whether natural or produced by drugs, and, that neither 
sensibility nor, usually, reflex activity is affected. Chorea electrica is 
merely a variant of chorea proper characterized by lightening-like 
movements. Huntingdon's chorea is hereditary, appears usually dur- 
ing the third decade and is characteristically constant and progressive. 
Mental deterioration is marked and it usually progresses to terminal 
dementia. The movements themselves are slower, the gait more swaying 
and the disease shoidd have a single descriptive name.* 

Friedreich's Ataxia. Nystagmus, scanning speech, scoliosis, talipes, 
the slow movements and clear evidence of heredity make the diagnosis 
clear. Hysteria. Rarely, cases may exactly simulate chorea, but usually 
the movements are less jerky and irregular, more rhythmic and there are 
associated stigmata which make the diagnosis easy. Rhythmic chorea 
of hysterical origin produces orderly movements of the muscle groups 
involved, for example, the salaam convulsion. 

CONVULSIVE TIC— (Habit spasm). This usually takes the form 
of localized facial spasm associated with head movements or the raising 
of a shoulder, though often the spasm affects only the eye or the mouth, 
or more commonly both. It is a somewhat common, transitory and 
unimportant condition. 

IMPULSIVE TIC— (Gilles de la Tourette disease). This is char- 
acterized by involuntary facial, brachial or general muscular move- 
ments, often violent, in association with marked disturbances of speech 
and sometimes of mentality. Articulation is explosive even to incoherence, 
mimicry may be present, usually in the form of repeated utterance of words 
heard or of actions seen, or, the frequent repetition of obscene words may 
accompany the spasm. The mental disturbances are similar, taking 
the form of obsessions or -fixed ideas. Even* action may be associated 
with an impulse to count to a certain number or to touch a certain object. 

PANDEMIC CHOREA.— This group of diseases, more closely 
allied to hysteria than chorea, is chiefly of historic interest, although 
rare instances are seen at the present day. The tarantella of the com- 
poser was suggested by the remarkable religious manifestations epidemic 
during the middle ages. These were characterized by the wildest ex- 



Speech and 
gesture. 



Mimicry. 



The taran- 
tella. 



* It is variously described as "megrim," "megrum," "senile," " chronic 
progressive," "adult hereditary" and "chronic," chorea. . 



SALTATORY SPASM. 



615 



citement, violent gesticulation, and dancing and leaping to the point of 
exhaustion. 

SALTATORY SPASM.— This is a transient or chronic condition 
characterized by sudden violent contraction of the leg muscles upon any 
attempt to stand. Marked mimicry of words and actions may be 
present, and heredity plays a part. 

PARALYSIS AGITANS.— (Shaking palsy, Parkinson's disease). 
Occurring more frequently in men than in women and seldom under 
the age of 40, this disease possesses no definite etiologic factors, nor 
has it any characteristic pathology unless it be a premature senility of 
a cerebro-spinal type. 

Symptoms. — The chief symptoms are tremor, rigidity, weakness and 
a peculiar attitude and gait. The disease, though insidious, is easily 
recognized when fully developed. The tremor chiefly affects the hands 
and feet, thumbs and forefingers showing the so-called "pill rolling" 
motion; the toes are less involved, the chief tremor in the lower ex- 
tremities being in the ankle joint, and head nodding, if present is usu- 
ally vertical, more rarely rotatory. Emotion increases tremor; volun- 
tary movement may or may not check it, and it is absent during sleep. 
Rigidity is shown in slow and awkward movements, and weakness may 
be the earliest symptom but often appears only after exertion. The 
face is immovable and expressionless, the eyebrows raised and the attitude 
and gait become characteristic as the disease advances. The patient 
stoops with bent head, with the arms held away from the body and 
flexed at the elbow and the fingers bent. The voice is high pitched and 
the speech curiously hurried though perhaps primarily hesitating. In 
walking festination is observed, the stooping patient apparently trying 
to overtake his centre of gravity (Trousseau) and if thrust backward 
the same short hurried steps are taken and the patient will fall if not 
supported. 

Diagnosis. — The developed disease is unmistakable and a diagnosis 
may be made on the basis of rigidity, weakness and attitude alone. It 
could only be confounded with post hemiplegic tremor from which the 
history will usually at once distinguish it. 

HYSTERIA. — The fact that one is dealing with a genuine disease 
should never be forgotten in relation to hysteria, and further, that it is a 
disease equalled only by syphilis in tJie protean nature of jfo manifes- 
tations. 

Etiology. — Heredity and early training are tJie most important factors 
in hysteria. Indulgence of whims, the development of the emotional 



Bread 

crumbling 

tremor. 



Rigidity. 

The mask- 
like face. 



Attitude, 
voice and 
speech. 

Festinant 

gait. 

Propulsion 

and retro- 
pulsion. 



A disease. 



6i6 



MEDICAL DIAGNOSIS. 



Heredity 
and early 
training. 



Harmful 
sympathy 



Treatment. 



Young 
women 
chiefly. 



Often asso- 
ciated with 
organic 
ailments. 



Sexual 
factors. 



Hysteric 
stigmata. 



side by excessive sympathy, the failure to demand of the child or 
young adult self control and consideration for others are factors that 
can seldom fail to create an hysterical temperament, particularly if the 
body be relatively feeble, the intellect precocious and the neuropathic 
hereditary taint marked. In such persons nervous instability, lessened 
will power and suggestibility, are often evident early. Grief, joy or 
even the minor worries of life produce hysteric seizures and the con- 
dition is aggravated and increased by the injudicious petting, solicitude 
and indulgence which such unfortunates receive at the hands of parent, 
husband, or even the physician. On the other hand the condition, 
when developed, must not be regarded as one depending upon the 
unassisted volition of the individual, or wholly subject to her control, 
but rather as an actual disease to be ameliorated and perhaps removed 
by a treatment which, though kind, is firm, persistent, insistent and 
lacking in every element that enters into the upbuilding of the hysterical 
temperament. 

Age, Sex and Race. — The disease occurs for the most part between 
the ages of 15 and 20, and almost exclusively in women, cases of hysteria 
in the male being the rare exception in this country. It rarely occurs 
in children under 10 and adults over 60. Southern races yield many 
examples as compared with the more Northern. Relation to Disease. 
It is found in combination with and as a result of actual disease far more 
frequently than is usually supposed, malnutrition and anazmia, lead and 
arsenic poisoning, unrecognized dyspepsias, gastric or intestinal, reflex 
irritation, naso-pharyngeal obstruction, or diseases of the pelvic organs, 
movable kidney, chronic appendicitis and unrecognized gastric ulcer 
being some of the causes encountered by the author. Physicians gen- 
erally err about as often one way as the other, failing on the one hand 
to recognize an underlying organic cause in certain cases, and on the 
other construing pure hysteria as the organic disease which it simulates. 
Sexual excess or sudden deprivation in certain instances is most impor- 
tant, though aside from those showing erotic posturing, etc., during 
attacks, the hysterical woman is usually sexually indifferent and the 
genesic sense may be abolished through anaesthesia. 

Symptoms. — These may be present in almost any portion of the 
body and consequently almost any disease may be simulated. Motor 
symptoms may be paralytic, paretic or spasmodic. Paraplegia and 
monoplegia are more common than hemiplegia. Paralysis is usually 
incomplete, muscles may show disuse atrophy, but the electrical reac- 
tions are normal, the knee jerks seldom diminished, usually increased 



HYSTERIA. 



617 



Contrac- 
tions rather 
than con- 
tractures. 



Some form 
of anaesthe- 
sia seldom 
absent. 



and equal, and a paralyzed leg is usually dragged limply along. 
Urinary retention may be seen, true incontinence never, true ankle 
clonus is absent, pseudo-clonus sometimes present; aphonia is frequent 
but the paralysis is seldom complete. Ptosis is usually double, often 
with an overactive orbicularis, but the muscles of the eyeball are seldom 
affected, though conjugate deviation rarely occurs. Both tonic and 
clonic spasm may occur, particularly after injuries and both paralysis 
and spasm may be associated with anesthesia. Pseudo -contractures, 
persisting during sleep but disappearing under general anesthesia, and 
fine tremor or regular and irregular muscular contractions and even 
edema are encountered. Hystero-epileptic seizures are common among 
the Southern races, but their differentiation is seldom difficult, though 
their various phases (i.e., prodromal, epileptoid, clownism, passional, 
delirious), may vary greatly in intensity or appear in an isolated form. 
Hypercesthesia is especially marked in the hysteric zones, i.e. the hypo- 
gastrium and lower spinal and injramammary regions but it may be 
visual, auditory or olfactory. Anozsthesia and more often, analgesia may 
be associated with loss of response to heat and cold and impaired 
muscle sense. Both motor and sensory paralyses affect the left more often 
than the right side, but sensory symptoms may involve the entire body, 
including the mucous membranes and in hemianesthesia they are 
characteristically limited by a well defined border representing the 
median line of the body. The stocking, garter, glove, sleeve or drawer 
leg forms are seen, as are irregular or disseminated islets of anaesthesia 
conforming to neither nerve nor segment distribution while they may 
capriciously shift their seat or boundaries after a seizure or without 
apparent cause. They may also take the form of concentrically con- 
tracted visual fields usually unequal and sometimes unilateral or hys- 
terical color vision (see page 555). The loss or perversion of special 
senses and loss of sensation is actual and not imaginary in all true 
hysteria, and the patient is usually unconscious of the latter. Absolute 
blindness or deafness is rare and monocular diplopia is a rare symp- 
tom. Mental symptoms range from mere hysterical laughing and cry 
ing, to amnesia, loss of willpower, impressionability, somnambulism, 
ami even the simulation of actual insanity. The pharyngeal reflex is 
lost in 90% of the cases of hysteria as is frequently the plantar reflex. 
Autohypnotism and catalepsy are among the rare conditions, the re 
Ilexes being lost in the latter condition. 

Diagnosis. Most cases are evident to any trained clinician and in 
those simulating organic disease oi the spine or cord some difficulty 



6i8 



MEDICAL DIAGNOSIS. 



Common 
causes. 



Mental 
depression. 



Irritability. 



Egotism. 



Headache 
and in- 
somnia. 

Emotional 
crises. 



may arise. The normal or increased knee jerk, absence of urinary 
incontinence and true ankle clonus, the normal electrical reactions, absence 
of true atrophy, and the active resistance of spasmodic contractures, i.e. 
the evident active resistance offered the examiner's hand, are quite 
unlike true spastic contraction. The onset of symptoms is moreover 
generally coincident with some violent emotion, shock, or injury. The 
disappearance of contractures during anaesthesia or sound sleep is also 
important and the minor seizures may instantly disappear under sharp 
ovarian (hypogastric) or supraorbital pressure. Disseminated sclerosis 
presents oftentimes a strong resemblance, but tremor is absent or 
markedly lessened when the patient is at rest, continuous in hysteria. 

Prognosis. — The prognosis in any case depends upon two factors, 
the ability to undergo a proper course of treatment and the physician's 
success in obtaining the co-operation of sensible and intelligent family 
members. In many instances surgical or medical treatment directed to 
the cure of underlying organic disease or the removal of reflex irritation 
completely removes the symptoms. 

NEURASTHENIA.— This ill-defined and protean ailment depends 
for its development upon much the same conditions as have been 
described under hysteria, hereditary predisposition being marked in 
most instances but the factors of over -work, mental strain and past 
disease are more prominent. Sexual excess, perversion or sudden 
deprivation cuts a considerable figure, but drug habit is a sequence 
rather than a cause. 

Symptoms. — The fundamental symptoms are those of an unstable 
and irritable nervous system. Hypochondria is a frequent feature and 
more or less marked mental depression, either constant or occurring 
at intervals, is the commonest symptom. As a result, minor worries 
or physical ailments are magnified or even created out of nothing, 
and a loss of interest in those matters which have formerly been an 
engrossing life factor, inability to concentrate the attention, lapses 
of memory, periods of irritability, faultfinding or passion may 
replace a kindly jovial temperament. Egotism and introspection 
united make the patient a bore to his friends, family and physician and 
with this goes usually an utter lack of appreciation of the equal rights 
of those about him. If, as usually happens, insomnia, cerebral pres- 
sure and headache appear, the fear of insanity may be uppermost in 
the patient's mind. Such are sometimes dominated by fits of restless- 
ness and give way to emotional crises. Threats of suicide are common, 
and attempted suicide not infrequent. Many shun society, others fear 



NEURASTHENIA. 



619 



to cross open spaces alone, yet others are terrified in passing high 
buildings or engines in operation, and may even show the same causeless 
anxiety in every relation of life (pantophobia). The local manifestations 
relating to the heart, lungs, stomach, kidneys, intestines, etc., are so well 
known as to need no special description. Practically every organ may 
be the focus and apparent source of symptoms closely related to those of or- 
ganic disease, and it should be said that here as in the case of hysteria the 
utmost care must be observed in distinguishing between neurasthenic states 
sequential to disease and removal only by attention to the primary cause, 
and those which represent a neurasthenic state only. From personal 
observation the author has become convinced that a large number of 
so-called neurasthenics are actually suffering from organic disease to 
which a neurasthenia is secondary, and it may further be affirmed that 
the great success attending rest cures is in some measure due to the wide 
therapeutic range of rest and its associated measures for improving 
nutrition in the domain of general medicine. 

The Special Senses. — Increased sensibility to pain and general 
hyperesthesia find their local expression in the special senses. Neu- 
rasthenic asthenopia is extremely common and acoustic disturbances 
hardly less so. The Muscles. Muscular weakness even to complete 
loss of power is said to be possible but in most instances is a purelv 
subjective nervous phenomenon. A patient who feels utterly exhausted 
may engage in golf, curling, horseback riding or some similar pursuit and 
find his fatigue disappear with exercise or preoccupation. Vaso-motor 
Phenomena. Relaxation of the peripheral arteries together with the irrita - 
ble heart so frequently observed, may give rise to subjective sensations of 
throbbing or auditory hallucinations of the same character, and, indeed, 
may produce visible peripheral pulsation and a pulse not distinguisJiable 
from that of aortic regurgitation* Capillary pulse is frequently observed 
and Osier reports cases of venous pulsation. The well known throbbing 
of the abdominal aorta leads often to an erroneous and usually inex- 
cusable diagnosis of aneurism, and local flushing and sweating anil cold- 
ness of the extremities are common symptoms. Sexual neurasthenia 
forms the basis of the most troublesome of the complaints that come to the 
physician. Nervous impotence may occur, troublesome sexual irritability 
is not uncommon and ovarian and testicular tenderness is often wholly 
neurasthenic. Symptoms simulating diseases of the cord, such as local- 
ized spinal tenderness, intercostal neuralgia, subjective Fatigue, panes- 
associated 



Subjective 
weakness. 



Misleading 

pulsations. 



The uh>s 
ician s bet* 
noir. 



* Siuii cases are more frequently 
neurasthenia and decided anaemia. 



witli a romhuution of 



620 



MEDICAL DIAGNOSIS. 



Vertigo. 
Speech. 
Reflexes. 



Danger of 
misinter- 
pretation. 



thesia and visceral neuralgias may be marked and incoordination is occa- 
sionally well developed. This, however, is a relatively rare symptom 
and more often vertigo, usually transient, is experienced. A very impor- 
tant sign in this connection is a defective articulation precisely sim- 
ilar to that of the early stage of paretic dementia. This is not in the 
author's experience an uncommon symptom though rarely existing in 
a marked degree. Reflexes, both superficial and deep, are usually in- 
creased but pupillary reflexes are normal, though occasionally the pupils 
themselves are dilated or unequal. 

Diagnosis. — A consideration of the etiologic factors in connection 
with the foregoing symptoms is usually quite sufficient for a diagnosis. 
It will be readily seen that insanity and paretic dementia in their early 
stages present almost typical neurasthenic symptoms, as indeed do certain 
of the degenerative diseases of the brain and cord. The physical exami- 
nation is of great value in the exclusion of organic disease but not other- 
wise. The absence of true hysteric paroxysms separates it from hysteria, 
nor do such patients present the more marked hysteric stigmata. A 
drug habit is often over-looked and the same is true of petit mal. As a 
matter of fact, however, 99 cases out of any 100 presenting the symp- 
toms detailed under this head are neurasthenics and the progress of the 
ailment in the case of insanity and paresis, together with the more pro- 
nounced earlier symptomatology, the disturbance of reflexes and other 
well known signs of organic diseases of the cord, such as locomotor 
ataxia and multiple sclerosis, leave little room for error. The diagnosis 
of neurasthenia rests, therefore, upon the basis of a thorough and care- 
ful examination of every case and such will almost invariably exclude 
any of the confusing disease factors and often relegate a supposed primary 
neurasthenia to an expression of anaemia, cardiac, renal, gastric or other 
organic disease. 

TRAUMATIC NEURASTHENIA AND HYSTERIA.— (The 
Traumatic Neuroses of Oppenheim). — (Railroad spine, railroad 
brain). No more difficult task presents itself to the physician than that 
involved in an opinion regarding the effect of injuries as represented 
by purely subjective or indeterminate objective symptoms and too often 
involving a large element of unconscious or deliberate deception. To 
do justice alike to an injured individual and the harassed and much 
bled corporation is at times well nigh impossible. 

Important Features of Traumatic Cases. — Aside from out and 
out malingering one may encounter one of four reasonably distinct 
clinical types, viz.: — (1). Those in which a pure neurasthenia is mam- 



Sec a pri- 
mary cause 



A difficult 
problem. 



Clinical 
types. 



TRAUMATIC NEURASTHENIA AND HYSTERIA. 



621 



jest. (2). Cases markedly hysterical. (3). Cases exactly resembling the 
first two groups but developing after a variable period actual disease of 
the brain or cord. (4). Cases of manifest injury. 

Neurasthenic Type. — This differs in no particular from ordinary 
neurasthenia save that the morbid introspection and mental depression 
relate to the accident and its supposed effects. 

Hysteric Type. — This is merely a neurasthenia with hysteric stig- 
mata added, the emotional side being pronounced. 

Symptoms Commonly Presented. — Headache, insomnia, vertigo, 
subjective weakness, mental and nervous irritability and instability 
are marked, mental depression is common and may reach actual 
melancholia. Pain in the back is almost invariable, the reflexes are 
increased and the impaired digestion and lack of appetite, together with 
the mental depression and anxious, drawn countenance, often lend a 
misleading facial element of suffering, emaciation and pallor. The 
tongue is usually coated and constipation is common. Numbness 
and tingling may be present in either the hysteric or neurasthenic types, 
but in the former may co-exist with either a mere limitation of the 
visual fields or an achromatopsia and a marked hysteric or emotional 
tremor is not uncommon. The pupils are often dilated and may be 
slightly unequal. Circulatory disturbances are common and tachycardia, 
marked cardiac irritability, arrhythmia and vaso-motor disturbances 
often persist for long periods. Subjective sensations of heat and cold, 
flushing, excessive perspiration or recurrent sweats, variations in the 
urinary secretion and the like frequently occur. Menorrhagia, amen- 
orrhcea, sexual neurasthenia and loss of memory may be added to the 
long list of symptoms usually representing purely functional disturbances. 

From personal observation the author believes that no line can be 
drawn between "traumatic neurosis" and traumatic neurasthenia 
or hysteria, for while at times cases arise that fit the syndrome first 
named, in many others there is a blend of signs that hopelessly blurs 
any sharply drawn boundaries and the element of deliberate or uncon- 
scious exaggeration too often fostered by alarmist opinions and vague 
theories on the part of the over-sympathetic physician pervades and 
weakens the whole diagnostic structure. He also doubts the frequency 
of "traumatic neuroses'' so called after trivial falls and injuries when 
not connected with claims for damages, ami lias more than once found 
them properly attributable to pre existing disease oi the heart or blood 
vessels, usually a myocarditis. In those predisposed to or actually 
suffering from neurasthenia or hysteria those conditions may readily 



Neuras- 
thenic and 
hysteric. 

Physiog- 
nomy. 



Paresthe- 
sias. 



Pupils. 

Tremor. 
Heart. 



Vaso-motor 

and miscel- 
laneous. 



Effecl of 

trivial 
injury. 



llou ex 
plained. 



622 



MEDICAL DIAGNOSIS. 



Actual 
conditions. 



Prognosis. 



Evident 
exaggera- 
tion. 



Sprains, 

fractures, 

etc. 



Mistakes 
common. 



Chief 
sufferers. 



be excited or intensified by slight trauma or excitement. There are 
probably but three actual conditions, viz.: — (i). Genuine injury to and 
actual lesions of the brain or cord. (2). Pure neurasthenia or hysteria, 
and (3) pure or adulterated malingering, usually for revenue. The 
diagnosis must depend upon the discovery of symptoms purely subjec- 
tive or of the neurasthenic or hysteric type on the one hand, or, definitely 
objective upon the other. Lacking objective signs after several months 
one is reasonably certain that the case will recover after settlement. 
With the signs of organic disease and only in their presence is the 
physician justified in a lugubrious prognosis on or off the witness 
stand. In fully 80% of such cases, examined by the author, in 
which suit was pending, the element of exaggeration was evident. In 
hardly any of those injured in a similar manner but without liability 
on the part of a corporation have there been any symptoms save those 
of direct injury such as bruises and sprains, neither has the pain in 
these been persistent over long periods, nor the mental and nervous symp- 
toms, save in exceptional instances, even in the cases associated with 
great primary mental shock. Indeed it must plainly appear to anyone 
experienced in these matters that the after symptoms in railroad injuries 
are remarkably in consonance with the degree of mental shock exper- 
ienced at the time. Finally there is the group of cases which are truly 
surgical or relate to actual visceral lesions and of fracture of the verte- 
brae, sprains, hemorrhage into or about the cord, myelitis and menin- 
gitis and are directly diagnosticable, though in rare and deplorable 
instances the delayed development of organic disease may result in an 
injustice to some honest suitor. 

MALINGERING. 

Until medicine becomes an exact science the physician will do well 
to give the benefit of any doubt to the supposed malingerer and avoid 
measures savoring of harshness or cruelty, or the giving of injurious 
testimony in a court of law, save when the case is clear and the imposture 
of a particularly barefaced or injurious nature. 

The chief sufferers from feigned diseases are railway, street car and 
accident insurance companies, but the evil extends to the army and 
navy, pension bureaus, and even to the home, and every physician 
must meet with numerous cases whatever may be his line of practice. 

No one class of diseases has any monopoly of this form of deception, 
though the nervous system lends itself most readily to the needs of the 
impostor, while on the other hand presenting more traps and pitfalls 



MALINGERING. 



623 



and in certain directions more difficulty in simulation than general 
diseases. 

The basis of the most serious types of malingering or imposture is 
the dollar and the lengths to which people will go in their attempts 
to defraud accident insurance companies especially is almost incred- 
ible. For many years these companies paid a large indemnity for the 
loss of the left hand and the number of claims incurred was so enormous 
as to lead to a reduction of the indemnity by one-half, following which 
the claims of this class fell off over 80%. 

Men will deliberately shoot themselves or place a hand or foot under 
the wheels of a moving train for the sake of the small amount of money 
represented by accident indemnity and similar examples of self muti- 
lation are found in the countries where military service is compulsory 
or in the case of soldiers tired of service and desiring a discharge; the 
common form being the mutilation of the trigger finger as furnishing 
the readiest and slightest injury incapacitating for active service. The 
minor frauds in this connection are consequently encountered by every 
physician and the unscrupulous man with an unrecognized but readily 
sprained flat foot or the still more fortunate possessor of a shoulder 
or hip that he can dislocate at will is reasonably sure of realizing some- 
thing from his infirmity. Furthermore, as is now well known, certain 
unscrupulous attorneys and equally unscrupulous physicians of the 
large cities form a criminal class known as "ambulance chasers." 
Such scoundrels will not only follow up cases of injury and suggest 
lawsuits but will furnish witnesses ready made, sworn physicians' 
statements of any desired character, and any other bit of criminal 
machinery needed in the given case. 

A Curious Case of Simulated Injury. — Amongst the many 
instances of professional malingering one will sufhce for illus- 
tration. A certain individual, following the usual custom of the criminal. 
took one special line as his own and the street car company as his 
object of attack. His procedure was simplicity itself; he would enter 
a street car carrying a cane bearing on its tip a screwdriver and while 
sitting in the car would quietly elevate a floor screw of the seat in front 
of him, then he would rise hastily to leave the ear, ostensibly trip over 
the screw head and in falling receive an apparently severe and painful in- 
jury. He would then summon a carriage and be driven rapidly home 

where he would take a tack hammer and after covering the knee, elbow 

or ankle joint with a few layers of cloth would pound the point selected 
until he had produced the necessary appearance of a severe joint injury 



Malinger- 
ing for 
revenue. 

Striking 
illustration. 



Army 
service. 



Flat foot 
and hip 
joint cases. 



Ambulance 
chasers. 



Malinger- 
ing extraor- 
dinary . 



624 



MEDICAL DIAGNOSIS. 



- - - - 
facts. 



Non- 
existent. 
Factitious 

Exagger- 
ated. 

I ~ a g : r. £ r ;. 



after which he summoned a physician. It is said that this went on for 
years aud that the man received in damages from different corporations 
a very decent fortune. As regards deliberate mutilations of the more 
serious type it should be remembered that the victims are usually 
urgent in their demand for amputation, frequently suggesting it and 
often insisting upon it. Such are usually holders of recently issued 
accident policies, and the mutilation is ordinarily just sufficient to come 
within the terms of the contract and seldom involves the most useful 
member; the left hand or foot being usually selected. 

Classification. — Disease or injury may be (a) wholly spurious and 
non-existent, or, (b) actual, but either selj produced, factitious or deliber- 
ately exaggerated or aggravated, (c) the deception may be an imn 
one due to a genuine belief in its serious nature on the part of the patient 
which opinion is usually fostered by friends and family and too often 
by an over-sympathetic physician. 

SOME OF THE COMMONER FEIGNED STATES.— Anse- 
mia. — By taking a nauseating substance pallor is readily achieved 
but the absence of anaemia is readily demonstrated by testing the 
blood. 

Angina Pectoris can be successfully simulated by one familiar 
with the subjective symptoms by swallowing tobacco and taking drugs 
which produce a disturbed heart rhythm, pallor and clammy skin, 
and simulating the paroxysmal seizures. It requires, however, a good 
actor. The tobacco or other drugs may be taken by the rectum and 
palpitation may be caused by extreme compression of the abdomen, 
indeed Herold states that hypertrophy may thus be induced, which 
statement we would be inclined to doubt. 

Aphonia. — Here the one reliable test is the volubility* of the patient 
during the stage of excitement or the after stage of recover}- from an 
anaesthetic. Xo condition is more readily simulated. 

Asthma of the spasmodic type cannot be successfully simulated 
nor can the severer form of dyspnoea because of the absence of cyanosis 
save in the case of a very patent holding of the breath. 

Atrophy of the Extremities. — A certain amount of atrophy may 
be induced by disuse and increased by the use of tight bandages. 

Blindness. — Amaurotic blindness is easily feigned by instilling 
atropia and is difficult to detect unless the patient can be thrown off 
his guard and carefully observed for a considerable period. Simulation 
of blindness, however, usually involves one eye and is oftentimes a 
mere exaggeration of an existing though trivial defect in refraction. A 



■ ai 



SOME OF THE COMMONER FEIGNED STATES. 



625 



pupil reacting normally to light excludes most forms of blindness but 
in all, the testing of the visual field will often reveal deliberate deception 
and a simple test consists in holding a pencil close to the sound eye 
and asking the patient when its tip is lost to his vision; he may still see 
it after it is passed behind the nose or deny it while it is manifestly in 
the range of the normal eye. If asked to look at an object held 
in his own fingers a malingerer feigning total blindness will often 
pretend that he cannot get the direction of the object while those 
actually blind will look at it, judging its position without hesitation. 
If a pencil is held between a book and the eye and double vision exists 
it does not interfere with the reading but if only one eye is competent 
reading is impossible as certain words will be cut out. This is an 
excellent test because the pencil can be thus used without attracting 
the attention of the malingerer. It must of course be held close 
to the eye and motionless. Lenses make still more difficult any 
fraud in connection with unilateral blindness. If, for example, a 
strong prism is placed in front of a sound eye, base up, and brought 
gradually in front of the eye from below upward double vision will 
occur before the base reaches the pupillary centre, one image directly 
transmitted, the other refracted. This being admitted by the patient, 
the prism is gradually pushed upward so as to obscure the pupil, pro- 
ducing a single image for that eye but if both eyes are competent a 
double image because of the different levels. If therefore a double 
image is still admitted as is almost invariably the case it proves vision 
in both eyes. Another test consists in using a 6 D convex glass upon the 
sound eye thus reducing the range of vision and making reading pos- 
sible only at 17 cm. or less. The patient is asked to read and the book 
gradually removed when it will be found ordinarily that the range is 
greatly exceeded or variable. Still another test consists in introducing 
a red glass before one eye and a green one in front of the other; the 
patient is then asked to look at Snellen's colored test types. Only 
the colored letters that correspond to the color of the glass in front oi 
the eye can be read by that eye and if one is blind unilaterally he will 
not even suspect the existence of letters other than those read by the 
supposedly sound eye. This test may also be made by using an ordinary 
pencil and a red pencil to make written characters of the two colors.* 
Cancer. -By a proper irritation of an existing sore in certain 
regions such as the breast or lip or by attaching to the skin a section 

♦ These n-sts are for the most pari derived from Fuch's "Text Hook oi 
Ophthalmoscopy." 



626 



MEDICAL DIAGNOSIS. 



of the spleen a passable imitation of cancer may be attained but the 
success of such impostures seems incredible if any examination be 
made and the patient under proper observation. 

Catalepsy. — This is imperfectly simulated as the maintenance of 
the forced postures characteristic of the true state is impossible, the arm 
or leg if extended soon tiring and dropping to the normal position. 

Cerebral Concussion. — This condition is often feigned but it is 
only necessary to remember that the genuine lesion is associated with 
superficial respiration, pallor and moist skin and usually with nausea 
or vomiting. 

Chorea is in itself difficult to simulate and readily detected if the 
subject can be observed when awakened from a sound sleep in which 
case he will for a moment forget his role. 

Consumption. — Only the stethoscope can unmask the skilful 
malingerer who chooses this ailment and if as frequently happens there 
is actual bronchitis the exposure depends upon the absence of physical 
signs of infiltration or cavity formation and of fever or bacilli in con- 
trast to the patient's apparent condition which is usually pitiable. The 
common method employed consists of: — feigned cough, bloody sputum, 
obtained by pricking the gums or when opportunity offers (as in hos- 
pitals) mixing ordinary sputum with blood or pus, and emaciation pro- 
duced by abstinence from food, drinking quantities of vinegar or chew- 
ing and swallowing large quantities of tobacco. 

Contractures. — Joint diseases with contracture or anchylosis offer 
an inviting field for the malingerer, but the joint in such cases is normal 
or becomes so if the patient is kept under observation and lacks imple- 
ments and opportunity for producing fictitious lesions. Pain is fre- 
quently associated with the lesion and is often of such a nature as to at 
once expose the attempted deception. Muscular atrophy save that of 
disuse is lacking, the patient resists by evident muscular contraction at- 
tempts to move the joint and an anaesthetic reveals motility and exposes 
the fraud. One simple method is often effective with this class, viz., 
having the patient stand and then suddenly pushing him off his balance 
when the supposed crippled leg will usually be extended for support. 
Another method is to place the patient, standing on one leg, upon some 
high object, as a stepladder, the sound limb being slightly flexed; mus- 
cular fatigue will often force the patient to bring down the affected leg 
for support. Yet another consists in suspending a heavy weight over 
the contracted limb and it soon yields to the steady pull. Another old 
procedure involves the use of an Esmarch's bandage, which being 



SOME OF THE COMMONER FEIGNED STATES. 



627 



tightly applied, prevents the muscular action which maintains the false 
contracture. 

Convulsions. — It is physically impossible to maintain for a long 
period the more violent convulsive movements and difficult to simulate 
correctly and in proper sequence those of the well known types. 
Nevertheless, even epilepsy may be exactly simulated by one having 
a thorough knowledge of the true disease and willing to go to the ex- 
tent of biting the tongue and passing urine during the paroxysm. 

Cutaneous Lesions. — These are readily simulated in many of their 
forms. A simple mustard plaster will produce erythema and may be 
cut in any form desired; pustules may be caused by croton oil; blisters 
by cantharides. Urticaria may be deliberately produced by eating cer- 
tain substances known to produce them in the given individual (shell 
fish, strawberries, etc.). Pruritus offers no difficulties to the malingerer. 
Dermatitis and ulcer may be produced by acids or caustics; gangrene 
or the appearance of it by constricting bands and indeed nearly every 
skin disease including alopecia, bromidrosis and chromidrosis may be 
accurately feigned but are of little consequence. Detection of most of 
them is easy if a fixed plaster-of-Paris dressing can be applied, the 
patient being then unable to keep up the necessary irritation, and in 
the case of simulated gangrene, stripping the patient will disclose the 
cause and close confinement and observation will result in a disappear- 
ance of the lesion. 

Diarrhoea and dysentery are both simulated, most commonly by 
mixing the fecal discharges with urine and adding blood from the finger 
or gums. Soap may also be employed and iron and bismuth taken 
by the mouth may add to the apparent abnormality. Such impostures 
ought never to be successful if a patient can be watched as the evacu- 
ations can be received in a pan and directly inspected. 

Dropsy, Edema, Ascites. — Edema may be produced in an extrem- 
ity by the use of a concealed ligature which however will leave its 
mark. It is even said that water has been injected directly into the 
peritoneal cavity. 

Dyspepsia. — No disease is more easily simulated because o\ the 
predominance of subjective symptoms in the real disease. The intro- 
duction of a stomach tube after a test meal, if accompanied by a posi- 
tive statement as to the certainty of its findings, may reveal the impos- 
ture, unless the simulator knows much oi the vagaries of the disorders 
of digestion. Another successful method is the buttermilk cure with 
absolute rest in bed without means o\ diversion. 



628 



MEDICAL DIAGNOSIS. 



Dyspnoea on exertion can be clumsily simulated but with normal 
heart, blood, lungs, and kidney is disproved. 

Calculi and gravel are frequently simulated, most commonly by 
urinary sediments, which are usually readily proven to be street gravel, 
brick dust, cinders or bone. In the female these substances are not 
infrequently actually introduced into the bladder or stored away in the 
vagina and used as occasion offers. 

Epilepsy. — As before stated this disease can be but is with diffi- 
culty simulated. It is employed by professional thieves and beggars, 
as it draws a crowd, diverts attention and excites sympathy. The use 
of a pinch of snuff often suffices to expose the fraud as will the injec- 
tion of apomorphia and occasionally the actual cautery or a threatened 
operation. Marked improvement under the administration of sodium 
chloride, the patient thinking that he is taking sodium bromide, may 
expose the supposed victim of chronic seizures. 

The Eye. — Diseases of the eye, aside from the blindness already 
mentioned, are readily simulated, a great number of irritants being 
ready to hand. In these cases the rapid onset of inflammation and its 
prompt subsidence after the withdrawal of the irritant exposes the 
fraud. Chronic inflammation as induced by beggars may be extremely 
difficult to detect and is often carried to the point of ulceration of 
tissue. 

Feigned Sleep. — It is said that in genuine sleep if the eye be sud- 
denly opened even in the presence of a bright light there is transient 
primary dilatation of the pupil. 

Fever. — Save in actual hysteria the simulation of fever is unsuc- 
cessful in the light afforded by clinical thermometers but nothing is 
commoner than the use of the hot water bag or a hot drink for the 
purpose of raising the temperature. Fever readings of any height are 
easily produced thus or by friction applied to the thermometer.* Chill 
is sometimes feigned but the malingerer is found hot and sweating 
under his blankets from the warmth and from his own exertions. 

Fistula. — Anal fistula is readily and often successfully simulated by 
making a cut and treating it with some irritant such as carbolic or 
one of the strong mineral acids, but usually it is clumsily done and the 
imposture detected. 

Fictitious Wounds. — Aside from mutilation under accident poli 
cies, fictitious wounds are not uncommon in connection with false 

* In a recently observed private case a much desired winter trip to the 
South was obtained by this means. 



SOME OF THE COMMONER FEIGNED STATES. 



629 



charges of assault or in the case of those who seek to disguise their own 
theft by the pretense of attack and injury at the hands of burglars. 
They are also employed as a means of establishing self defense in 
cases of actual or attempted homicide. The most significant factor in 
their detection is in the comparatively trivial nature of the injury, the 
fact that knife wounds are inflicted in the region most accessible to the 
hand commonly used by the individual or as is often the case such 
cuts and gunshot holes are made in the clothing to intensify the ap- 
pearance of a struggle, as should manifestly have involved the skin 
or body. Attempted suicide by throat cutting with the razor or knife 
may be denied or concealed but the characteristic incision obliquely 
downward and forward from the angle of the jaw on the side opposite 
the arm commonly in use is usually sufficiently characteristic. 

Fractures. — Simulated fractures can only impose upon ignorance 
and are absolutely exposed by the X-Ray. 

Headache. — Feigned headache can hardly be detected with cer- 
tainty though close observation by the physician or nurse and the 
readiness with which sleep is produced may in some cases be im- 
portant. 

Heart. — Save in the rare instances of inhibition of the heart ac- 
tion, cardiac ailments are simulated only by producing palpitation 
and changes in the pulse rate. Sly compression of an axillary artery 
or the use of a concealed ligature may produce unilateral weak pulse. 
Digitalis in full doses may produce an apparent bradycardia, or, if 
pushed still further, an irregular and tumultuous heart action. Cardiac 
dilatation or hypertrophy, valvular murmurs and abnormally accentu- 
ated heart sounds are not readily simulated. 

Hemorrhages.- — The commonest are those simulating hemoptysis, 
haematemesis, and hemorrhoids. The saliva may be clumsily cov- 
ered with dyes, brick dust, etc., or, more commonly, mixed with 
genuine blood obtained by pricking the gums or fauces. If the symp- 
toms of tuberculosis are absent both as to fever and physical signs a 
solution is relatively easy. Hcrmatrmcsis may be simulated by pricking 
the gums and swallowing the blood which is afterwards vomited; it 
constitutes one of the most difficult of all impostures for the medical 
examiner, particularly if associated with feigned pain by one having a 
knowledge of gastric ailments. The sources of anal hemorrhage are 
readily detected by local examination, further they result from cutting 
or pricking the parts or from the introduction of blood, the lesion being 
evident upon removal of the blood which shows no possible source for 
41 



630 



MEDICAL DIAGNOSIS. 



the hemorrhage. In some instances substances such as inflated fish 
bladder have been introduced to simulate hemorrhoids. They are 
readily detected by local examination. 

Hernia. — Inflation of the cellular tissue of the scrotum and in 
some instances voluntary retraction of one testicle have been employed 
but the fraud is readily detected by the behavior of the supposed 
intestinal coil under manipulation, or the absence of one testicle. 

Hydrocele. — Attempts to simulate this lesion by injecting water 
into the tissues of the scrotum are clumsy and unsuccessful and in any 
event readily detected by drawing off a portion of the fluid. 

Hydrocephalus. — Pseudo -hydrocephalus has been produced by the 
injection of air into the cellular tissue of the scalp. The crackling 
on palpation and peculiar .fascial distribution should at once excite 
attention. 

Hydrophobia is frequently simulated but is usually greatly over- 
done and readily detected. 

Hysteria may of course be readily simulated but is an absurdity. 

Incontinence of Urine. — This is oftentimes extremely difficult to 
detect, but it is frequently possible to make the circumstances sur- 
rounding it so embarrassing as to expose the deception. The steady 
drip of overflow incontinence cannot be simulated if the patient is 
closely observed. 

Insanity. — The following points may be of sendee in this fre- 
quently feigned disorder. Melancholia. A sudden onset with loss of 
memory and dementia at once proves the ailment spurious. Mania. 
A sudden onset lacking all relation between the surroundings and the 
patient's ideas, the relatively easily induced fatigue and natural sleep 
proves the falsity of the ailment. Maniacal Frenzy. Absence of a pre- 
liminary period of depression and loss of memory of events just prior 
to the attack are the two chief signs of fraud. Paranoia. The feigned 
disease is indicated by the obstrusiveness of the assumed delusions, the 
usual evidence of a capacity to weigh and judge the effect of statements 
made and the lack of elaborately systematized delusions. Paretic De- 
mentia. A sudden onset, the absence of eye symptoms, the lack of true 
speech defects of the well known type are sufficient to establish the 
deception. Loss of Memory. The radical error of impostors is their 
failure to observe the fact that in all forms of dementia the loss of 
memory is of the senile type affecting recent events but not necessarily 
remote ones and often seeming to intensify those dating back to child- 
hood and youth. In the less extreme form of genuine amnesia the 



SOME OF THE COMMONER FEIGNED STATES. 



63I 



memory remains for striking events, the very ones in fact that a crim 
inal seeking to escape punishment will forget. 

Insanity is moreover extremely difficult to simulate and demands a j 
knowledge of the various types, possessed by few. Not only is failure 
of memory usually exaggerated and often intermittent and inconsistent 
but the facial expression is difficult to assume and the demands upon the 
simulator for consistency in speech and action are seldom met. The 
person feigning dementia almost invariably pretends to have forgotten 
all events, but the true dement has usually a clear or partial recollection 
of prominent circumstances or events antedating his disease. 

Jaundice cannot be successfully simulated because of the impos- 
sibility of maintaining the yellow discoloration of the conjunctiva when 
supplies are cut off. Turmeric has been used to color the skin, HC1 
added to the stools to make them clay colored, rhubarb ingested to 
give the urinary color and sometimes the eyes are deliberately inflam- 
ed to hide the deficiency in that region. 

Joints. — See "contractures," "rheumatism" and "limping". 

Limping. — Careful observation of a person using a cane or crutch 
may establish the fact that it is not being made a genuine support. 
Pretended stiffness of joints is revealed by the use of an anaesthetic 
and the absence of all inflammatory signs, joint crepitation, etc., will 
usually suffice to detect fraud. 

Lumbago may be successfully simulated and is the favorite form, 
fortunately the treatment ordinarily pursued is sufficiently heroic to 
make it of short duration. 

Ozena is said to have been feigned by the introduction of ripened 
highly odorous cheese into the nostrils. 

Pain and Tenderness.— These are extremely difficult symptoms to 
detect the falsity of, being wholly subjective, yet if the patient be under 
close observation it is seldom difficult to expose the fraud. Few can 
carry on a conversation while the physician is examining the body and 
still be prompt to respond to pressure made with one hand over the sup- 
posed tender area while a more vigorous and obtrusive procedure is 
being carried on elsewhere with the other hand. Furthermore, the 
administration of morphia may suggest fraud, either by the relief of 
pain afforded by a small dose or a spurious one or by the assertion oi 
persistence of pain or tenderness after the administration oi full doses; 
nearly all eases of this kind are overdone and the pain is referred to 
vague, indeterminate, shifting or unusual locations. If. moreover, such 
a patient can be examined during sleep such as that produced by Mil- 



632 



MEDICAL DIAGNOSIS. 



phonal or some other pure narcotic in moderate dose it will be found 
that the tender areas do not exist and that the pain which should pre- 
vent sleep does not affect it. 

Paralysis. — This condition can hardly be feigned with success if the 
examination be thorough and in competent hands. Its description 
would involve a rehearsal of the signs and symptoms of the paralyses 
resulting from the lesions of individual nerves or nerve groups and the 
different areas of the brain and cord as well as the phenomena of hysteric 
paralysis. It may be well to remind the reader that in the last named 
disturbance loss of sensation in the extremities stops sharply at the junc- 
tion of the limb with the body and if unilateral, is sharply limited 
by the median line and is likely to affect the whole body, including the 
face and scalp. Furthermore, the reflexes in this condition are likely 
to be bilaterally increased even though the paralysis is unilateral. 
Feigned anaesthesia is best detected by the unexpected application of the 
electric brush and it is impossible for a malingering patient to main- 
tain the fixed boundary line of a true anaesthetic zone; repeated exam- 
inations revealing marked variations. So also partial general anaes- 
thesia will almost invariably unmask feigned paralysis. 

Peritonitis, — Is often simulated but seldom successfully; one of 
the most common lapses being a restlessness on the part of the patient 
sharply in contrast with the fixed position assumed in true peritonitis; 
the true facies and pulse cannot well be simulated. 

Rheumatism can only be successfully feigned in its acute form by 
pounding the joints and this is seldom carried to the point of pro- 
ducing any misleading resemblance. The fever and peculiar sweating 
are beyond the patient's resource if he is under observation and the 
lesions rapidly fade. 

Retention of Urine. — This cannot be simulated if the patient is 
carefully watched. 

Sciatica. — This frequently feigned disorder is oftentimes readily 
detected by the clumsily described referred pain and points of tender- 
ness. Few genuine cases lack maximum tenderness midway between 
the sciatic notch and the knee even though the other points are 
insensitive. In the genuine disease, moreover, if the extended leg 
is flexed upon the pelvis the pain is severe though the opposite move- 
ment causes little distress. In spurious cases the patient may walk 
upright though limping and feigning great pain and distress, whereas in 
the true sciatica the thigh is always more or less flexed and the body 
inclined forward. 



SOME OF THE COMMONER FEIGNED STATES. 



t>33 



Scoliosis. — Feigned scoliosis is almost invariably dorso-lumbar, 
the spinal axis is not changed as in the true ailment, the skin is more 
markedly involved and the secondary compensatory curve is absent. 

Scurvy cannot be simulated except by deliberately taking mercury 
to the point of excessive salivation, and swelling of the gums will other- 
wise seldom or never be encountered. 

Unconsciousness. — Aside from ovarian and supraorbital pressure 
in the hysterical cases, the application of a sharp electric current and 
similar drastic measures, by far the best procedure is that of adminis- 
tering ether when the patient will invariably struggle and probably 
talk during the stage of excitement unless the unconsciousness is real 
when there will be no response. 

Venereal Diseases. — Such simulation is not infrequent in connec- 
tion with blackmail. Artificial eruptions are as readily produced on 
the genitalia as elsewhere and a fair imitation of gonorrhoea can be 
produced by the use of caustics or other irritants whether in the 
female or in the male, but the absence of the gonococcus is readily estab- 
lished and the peculiar characteristics of a primary sore are not easily 
simulated. 

Vertigo. — It may be impossible to detect spurious vertigo, though 
here as elsewhere close observation may result in catching the patient 
off guard. 

Vomiting. — This may be a very difficult form of malingering to 
detect but is usually so causeless or so directly and immediately related 
to the taking of bland substances as to expose its real nature. It may 
often be detected by making the circumstances under which it would 
occur particularly embarrassing to the impostor. In a case of hysteric 
vomiting observed by the author a cure was effected by forcing the 
patient to go to the theatre for an evening. 

Wry Neck. — This is usually readily detected by the muscular 
rigidity which follows any attempt on the part of the physician to 
correct the deformity. Furthermore the associated unilateral atrophy 
cannot be simulated and the condition disappears during sleep or 
anaesthesia. 

Comment. — In conclusion one may say that in all simulated dis 
eases detection depends upon (a) the incongruity and lack oj proper 
sequence in the symptoms presented; (b) the presence oj a mot:, 
simulation and (c) the patienCs actions and the course oj his ailment 
when under close observation and control or in the presence oj shock, 
surprise, suggestion, and finally the use oj drugs and OHGStheHcs, Bl 



634 



MEDICAL DIAGNOSIS. 



far the most difficult cases are those occurring in the domestic circles 
where the physician must use great tact and judgment and is usually 
obliged to make the patient expose himself. It may be added that the 
ruse so often suggested of allowing patients to overhear conversations 
calculated to produce absolutely spurious symptoms is successful only in 
the case of stupid and ignorant patients, the brainy impostor being ordi- 
narily prepared for such manoeuvres. On the other hand in many 
instances the simplest of measures suffice for exposure if the patient 
is under control, among the commonest being the mere threat of oper- 
ation, the administration of nauseating drugs or the establishment of 
an attenuated or unpleasant dietary and irksome restraint. 

CONDITIONS SIMULATING DEATH.— Asphyxia.— In drown- 
ing especially, death is often only apparent and resuscitation possible 
after long periods of submersion (one hour or even more). The same 
is true of infants apparently born dead. Efforts to restore life in such 
cases should therefore be carried out for a long period before hope is 
abandoned. 

Catalepsy. — In this condition the simulation of death is not ordi- 
narily sufficient to lead to error although both respiration and circula- 
tion may be but faintly indicated, superficial reflexes lost, analgesia 
and anaesthesia present and the temperature decidedly low. In 
the "trance state" the simulation of death is much more perfect, the 
limbs being flaccid or showing a rigidity simulating rigor mortis, the 
face pale and the pupils often fixed in dilatation. In these cases the 
question of voluntary inhibition of the heart action and respiration is 
interesting and there can be little doubt that certain of the East 
Indian fakirs possess this power. In the case of Colonel Townsend 
as described by Cheyne, the mirror test and stethoscope failed to 
reveal any sign of respiration or heart action for fully half an hour. 

Syncope. — (Fainting). As this represents a temporary failure of 
respiration and heart sounds and is associated with complete uncon- 
sciousness and pallor it perfectly simulates death but lasts ordinarily 
but a few seconds. 

Signs of Life in Persons Apparently Dead. — This title seems to 
the author more appropriate than the usual one, viz.: — "Signs of 
Death. " In the trance state or in those who can voluntarily inhibit 
heart action the pulse may be absent and the heart sounds inaudible, 
but the following signs will be present if the patient is living, ist. A 
deep red or purple color in the finger tips will be evident if a firm liga- 
ture be applied to the digit. If applied to the wrist prominence of the 



A BRIEF SUMMARY OF ACUTE POISONING. 



635 



veins on the dorsum of the hand indicates life. The ligature must not 
be so tight as to completely cut off the circulation. 2nd. Several hours 
after a supposed death blood flows persistently from a cut. A small artery 
should be chosen, not mere wet cupping or haphazard puncture, yd. If 
a needle thrust into the tissues and left for a time becomes oxidized, life is 
present. 4th. If any cloud repeatedly appears upon an ice cold mirror held 
close to the mouth there is respiration but its absence does not alone suffice 
to prove death. $th. If a powerful vesicant produces redness or blisters 
there is life. 6th. If a body fails to take approximately the temperature 
of its environment 48 hours after cessation of rigor mortis there is life, 
jth. Pupillary response to light shows life, its absence does not prove 
death. Several hours after death it is affected neither by atropin nor 
eserin. 8th. Persistence of the red in and visibility of the arteries of the 
optic disc are signs of life as is persistent clearness of the media (6-8 
hours after apparent death), gth. A sensitive cornea is a sign of life, 
absence of the corneal reflex is not a sure sign of death. 10th. Presence 
of electric excitability in all muscles 24 hours after death indicates life. 
(Usually lost in from 3 to 6 hours but retained for from 10-15 m cer " 
tain cases.) 

A BRIEF SUMMARY OF THE SYMPTOMS AND TREAT- 
MENT OF ACUTE POISONING. 

ACIDS, MINERAL.— (HN0 3) H 2 S0 4 , HC1). 

Symptoms. — Burning pain in the mouth, esophagus and stomach, 
vomiting of grumous liquid containing shreds of tissue; mind 
clear, intense thirst, dysphagia and usually dyspnoea or actual suffoca- 
tion, scanty or suppressed urine, constipation and profound shock. 
Acid Stains on Mucous Membranes: — Sulphuric. White turning to 
dark brown or black. Nitric. White, then orange, then brownish 
red. Hydrochloric. White or gray. Duration of fatal period: — Several 
hours or months depending upon amount taken, etc. 

Treatment. — Cardiac stimulants, morphia to relieve pain, baking 
powder or bicarbonate of soda in milk, egg albumin, carbonate of 
magnesia, calcined magnesia, mucilaginous liquids, sweet oil, olive oil, 
chalk, whiting, soap and water; the stomach tube or pump being barred. 
All treatment fails if pure acid lias been swallowed in quantity. 

ACONITE. (Acottitum Xupellus, monkshood, wolfsbane. Fatal 
dose: So min. of the tincture, maximum medicinal dose 1 to 5 min.V 

Symptoms. (Usually come on in a few minutes or mav be delayed 
one hour or more.) Pallor, dryness and tingling of lips, tongue, pharynx. 



6 3 6 



MEDICAL DIAGNOSIS. 



then of extremities and finally of whole body, nausea, perhaps vomiting, 
pharyngeal constriction (subjective); slow, weak, later rapid and irreg- 
ular pulse, subnormal temperature, slowed, shallow and irregular 
respirations, vertigo, dimness of vision, tinnitus aurium, clammy 
anaesthetic livid skin, dilated pupils if convulsions are present, 
profound prostration and death. Fatal period from 30 minutes to 5 
hours. 

Treatment. — Absolute rest. Evacuation of stomach by tube or 
stomach pump if condition permits, elevation of foot of bed, external 
heat, cardiac stimulants, artificial respiration, hypodermoclysis, hot 
rectal enemata. Tannin and charcoal may be given but are probably 
of little use. Large doses of digitalis seem effective (m xx-5i). 

ARSENIC— (Fatal dose 1 to i\ grs., retained). 

Symptoms. — (After half an hour or more), thirst, epigastric pain 
and tenderness, nausea, vomiting, purging with tenesmus, muscle 
cramps, rapid labored respiration, incessant and violent retching, pulse 
weak and rapid, urine scant or suppressed, cold wet cyanotic skin, 
perhaps paralysis, convulsions and coma. 

Variations — Cerebral symptoms may predominate, pain and vomit- 
ing may be absent or gastro- enteric symptoms be exceptionally violent. 
The usual picture is that of cholera morbus. Average duration in fatal 
cases between 8 and 72 hours, shortest 17 minutes. 

Treatment. — Evacuation of stomach, bland and mucilaginous 
drinks, ferric hydroxide (ferric chloride precipitated by any alkali) 
in milk, barley water, etc., followed by castor oil. 

ATROPIN. — (Belladonna. Fatal dose of atropin | gr.) 

Symptoms. — (After ^-2 hours). Dry hot throat, dysphagia, vertigo, 
dilated pupils, blurred vision, flushed face, brilliant eyes, rapid pulse 
and respiration^ active or even maniacal delirium, hallucinations, 
nausea, vomiting, scant, bloody or suppressed urine, sometimes 
strangury and priapism; scarlatiniform rash on face and neck, some- 
times general; stupor and death. It should be remembered that 10-15 
drops of the urine in such a case will dilate the pupil of any animal 
except birds and monkeys. 

Treatment. — Evacuation of the stomach and bladder, morphine, 
pilocarpine, tannic acid, cardiac stimulants. 

CANTHARIDES.— (Fatal dose 24 grs. or 1 oz. of tincture). 

Symptoms. — Abdominal pain, vomiting, dysenteric purging, dys- 
phagia, loin pain, dysuria, strangury and frequently priapism in the 
male, hot and swollen labia in the female or actual frenzied eroticism. 



A BRIEF SUMMARY OF ACUTE POISONING. 



637 



Treatment. — Evacuation of stomach, cathartics and bowel flushing, 
opium, cardiac stimulation, demulcent drinks but no oils, chloroform 
inhalations. 

CARBOLIC ACID.— (Fatal dose usually 5~5i but less would 
probably suffice, depends largely on dilution and stage of digestion). 

Symptoms. — Odor of acid on breath, whitened mucous membranes 
from contact. Burning pain throughout affected tract, vomiting, 
retching, contracted pupils, insensitive cornea, dyspncea, respirations 
rapid and shallow, stertor, collapse, coma and perhaps convulsions. 
Urine scant or suppressed, smoky, sometimes black or bottle green. 
Fatal period — few minutes to several hours. 

Treatment. — Dilute alcohol, whiskey, brandy in quantity, then 
evacuation of stomach; epsom salts, saccharated lime, soap and water 
may be used and demulcent drinks. 

CAUSTIC ALKALIES.— (Sodium and potassium hydrate, am- 
monia). 

Symptoms. — Same as corrosive acids except that there is dysenteric 
purging. 

Treatment. — Oils, dilute vinegar, lemon juice, cardiac stimulants, 
morphia, milk, mucilaginous drinks. Stomach tube contraindicated. 

CHLORAL HYDRATE.— ("Knock out drops," etc.). 

Symptoms. — Stupor or coma, pallor, either slow or rapid feeble 
pulse, slow respiration, pupils first contracted, later dilated, marked 
muscular relaxation, cardiac failure. 

Treatment. — Cardiac stimulants followed by hot packs and brisk 
friction, artificial respiration, hypodermoclysis. 

COCAINE. 

Symptoms. — Nausea, vomiting, mental excitement, delirium, rapid 
pulse and respiration, dilated pupils, fever, convulsions, stupor, coma. 

Treatment. — Cardiac stimulants, inhalations of chloroform to con- 
trol convulsions, evacuation of stomach, morphia. 

COLCHICUM.— (Fatal dose £ oz. of wine or less). 

Symptoms. — Those of a violent gastro-intestinal irritation with 
dilated pupils, cramps, perhaps delirium or convulsions, collapse, urin- 
ary suppression, partial or complete. Fatal period a few hours to sev 
eral days. 

Treatment. — Cardiac stimulants, hypodermoclysis, morphia. 

CROTON OIL.- (Fatal dose 30 m.V Typical choleriform symp- 
toms, collapse. 

Treatment.- Symptomatic. 



6 3 8 



MEDICAL DIAGNOSIS. 



CASTOR OIL.— Same symptoms. 

Treatment. — Symptomatic. 

CORROSIVE SUBLIMATE.— (Mercuric chloride. Fatal dose:— 
3 grs.). 

Symptoms. — Immediate choking, burning pain in epigastrium and 
esophagus, metallic taste, nausea, vomiting, persistent retching, dysen- 
teric purging, distended tender abdomen, shock, dyspnoea, muscle 
cramps, syncope, stupor, convulsions. Salivation not immediate and 
sometimes absent. Poison has an acrid coppery taste as compared 
with arsenic and, in the case of the latter, symptoms are delayed and 
the stools are less often bloody. 

Treatment. — Evacuate stomach, morphia, cardiac stimulants. Give 
white of egg in milk in quantity or flour paste. 

FORMALDEHYDE.— This produces intense abdominal pain, 
lachrymation and nasal irritation (fumes), cyanosis and cardiac failure. 
The odor of the breath is characteristic. 

Treatment. — Evacuation by stomach pump if apomorphia fails, 
ammonia by inhalation and the same drug (dilute) by the mouth if 
possible; morphine, cardiac stimulation 

GELSEMIUM.— (Fatal dose 5i of fluid extract or 3iv of tinc- 
ture). 

Symptoms. — Extreme muscular weakness. O ado-motor paralyses 
chiefly ptosis, blurred vision, fixed and dilated pupils, jaw drop, face 
pallid, congested, livid, cold sweat, impaired speech, dyspnoea (res- 
piration slow), partial paralysis of extremities, marked cardiac depres- 
sion, occasionally pharyngeal spasm or general convulsions. Fatal 
period, one to several hours. 

Treatment. — Evacuation of stomach, morphine freely, cardiac stim- 
ulants, hypodermoclysis. 

HYDROCYANIC ACID.— (Prussic acid. Fatal dose about 5i of 
official preparation or i gr. of anhydrous acid). 

Symptoms. — Immediate, in large doses, vertigo, muscular relaxation 
(patient falls), protruding eyes, locked jaws, slow, gasping respiration 
(respiration prolonged), dilated pupils, insensitive conjunctiva, pulse 
feeble, extremities cold, convulsions may occur, the face is livid and 
bloated, the lips foamy, the breath carries the distinctive odor of bitter 
almonds and death occurs in coma with stertorous breathing or con- 
vulsions. 

Fatal Period. — A jew minutes. Death is not instantaneous as is 
commonly believed. 



A BRIEF SUMMARY OF ACUTE POISONING. 639 



Treatment is usually futile, impossible or unnecessary, the patient 
being dying, dead, or out of danger in a few moments. 

LEAD ACETATE.— (Max. fatal dose about i oz.). 

Symptoms. — Sweet metallic taste, violent vomiting and a particu- 
larly intense abdominal colic with a rigid retracted abdomen, intense 
thirst and obstinate constipation, or, more rarely, a diarrhoea with 
black stools, vertigo, convulsions and stupor or coma. The blue line 
may be present even in acute poisoning. Fatal period, a few hours to 
several days. 

LOBELIA. — (Indian tobacco. Fatal dose 3i of leaves). 

Symptoms. — Nausea, vomiting, perhaps purging, cold sweats, con- 
tracted pupils, collapse, coma. 

Treatment. — Evacuation of stomach. External heat, cardiac stim- 
ulants, morphia, tannic acid. 

MUSHROOM POISONING.— (Usually Agaricus muscarius or 
vernus). 

Symptoms. — Violent abdominal pain, vomiting, purging, mental 
and nervous excitement, dyspnoea, stertor, collapse. 

Treatment. — Large doses of alropia* hypodermoclysis, external 
heat, cardiac stimulants. Empty stomach if necessary. 

OXALIC ACID. — (Frequently taken for epsom salts). Fatal dose 
3iv. 

Symptoms. — (Immediate.) Violent vomiting, often bloody, or, 
acute pain in head, neck, back and limbs with tingling or numbness, 
tetanic spasms or convulsions, aphonia and marked cardiac weakness 
or collapse. Usually fatal within one hour, perhaps in a few minutes. 

Treatment. — Never give potassium or sodium salts but rather chalk 
and magnesia in milk, oils, lime water, morphine and cardiac stimu- 
lants. 

OPIUM. — (Fatal dose 4-5 grains; laudanum 5 i, or their equivalents. 
In children trifling doses have caused death. Habitues may use several 
hundred grains daily.) 

Symptoms. — (Usually within from 3 to 30 minutes.) Somnolence. 
vertigo, stupor, coma, according to dose, the pupils are contracted ("pill 
point") and almost invariably equal, pulse slow and full, later weak 
and compressible. Respiration slow and stertorous, skin at first flushed 

*This treatment was first successfully applied by Dr. Jacob E. Schadle, 
of St. Paul, who in a personal communication states that the dose should 
be gr. 1 ',„ repeated as necessary and that gr, | may be required during 14 

hours. 



640 



MEDICAL DIAGNOSIS. 



and warm, later clammy, with diminishing respiratory rate. Pupils 
may dilate as death approaches. The fact that contracted pupils may 
occur in pontine hemorrhages and uraemic poisoning (Reese) must not 
be forgotten. 

Duration of Fatal Period. — 7-12 hours. 

Treatment. — Evacuate stomach (apomorphia 1-10 gr., stomach 
pump, etc.). Hypodermic injections of atropine, administer strong 
coffee; exercise mild cases and dash cold water over chest to excite 
respiration. Use artificial respiration and cardiac stimulants. Admin- 
ister 10 grains oj potassium permanganate in 6-8 ounces oj water. 
Empty bladder, use hypodermoclysis. In doubtful cases note odor of 
breath (laudanum) and search for hypodermic punctures, old or recent. 
Cocaine and adrenalin have been recommended and repeated lavage 
is valuable. Death occurs from respiratory failure indicated by in- 
creasing lividity and irregularity and slowness of respiration. 

PHOSPHORUS.— (Fatal dose:— 1 -10 grain has killed). 

Symptoms. — (Usually delayed several hours), "garlicky" breath, 
nausea, violent vomiting, abdominal pain, either diarrhoea or constipa- 
tion, dilated pupils, cardiac depression. Vomited matter is green and 
is luminous in the dark; in protracted cases jaundice and hemorrhages 
from mucous membranes (especially hasmatemesis) or, under skin. 
Urine scant and albuminous, or suppressed. 

Treatment. — Ordinary oils must not be used. Evacuate stomach by 
use of copper sulphate, purge freely and repeatedly; give old oil of tur- 
pentine in emulsion, albuminous and mucilaginous drinks (barley 
water, milk, flaxseed tea, egg albumin, etc.).* 

POTASSIUM NITRATE.— (Nitre, saltpetre). 

Symptoms. — Same as caustic alkalies but less marked, with tremor 
and perhaps convulsions and delirium. 

Treatment. — Evacuate stomach and give milk, barley water, flax- 
seed tea, cardiac stimulants and morphia. 

POTASSIUM CHLORATE. 

Symptoms. — Vomiting, purging, aesthenia, delirium, spasm or con- 
vulsions, acute nephritis. 

Treatment. — Same as preceding. 

STRAMONIUM AND HYOSCYAMUS.— Same as belladonna. 

STRYCHNINE.— (Nux vomica). Fatal dose gr. §. 

Symptoms. — (After 15-30 minutes), constriction of the throat or 

* H. C. Wood states that American oil of turpentime is valueless in this 
condition. Crude French oil is undoubtedly best. 



A BRIEF SUMMARY OF ACUTE POISONING. 



641 



subjective dyspnoea, muscular twitching of the face, followed by jerking 
of the head and extremities, and violent tetanic spasm (usually opis- 
thotonos) associated with lividity. Contraction of the facial muscles 
produces the "risus sardonicus," there may or may not be locking of 
the jaw (if so it comes on last and relaxes first in the spasms), and as in 
hydrophobia, spasm may be induced by attempts to administer water. 
Relaxation follows in from \ to five minutes and there is marked 
exhaustion and profuse perspiration. After a few minutes the spasm 
recurs and they increase in frequency and severity until death ensues 
from exhaustion or asphyxia. The special senses are exquisitely acute 
and a noise, draught of air, or sudden bright light may induce spasm ; 
vomiting is usually absent. It should be noted as separating this con- 
dition from hysteria, that the eyes are opened and the mind clear until 
the last or until the supervention of asphyxia if the case thus termi- 
nates. Unlike trismus proper the jaw muscles are involved late and the 
convulsions are intermittent with periods of complete relaxation. Fatal 
period, 5 minutes to several hours. 

Treatment. — Absolute quiet in a darkened room, evacuation of 
stomach after chloroform inhalation has been started, bromides and 
chloral, atropine. 

TARTAR EMETIC— (Fatal dose 1-2-40 grs.). 

Symptoms. — Almost exactly as in arsenic poisoning with profound 
cardiac depression. 

Treatment. — Same as arsenic save that tannic acid, not iron, is the 
antidote (strong green tea, etc.). Morphia and cardiac stimulants are 
indicated . 

TARTARIC ACID.— (One oz. has proved fatal). 

Symptoms. — Violent gastro-intestinal irritation. 

Treatment. — Sodium bicarbonate, magnesia, chalk, best adminis- 
tered through stomach tube which permits emptying stomach of con- 
tents and generated gas. 



642 



MEDICAL DIAGNOSIS. 



TABLE OF APPROXIMATE METRIC EQUIVALENTS. 



Grains 
or 






Grammes 


Grains 
or 






Gramme 


Minims or (c.c.) 


Minims or (c.c.) 


zoo- . . = .OOO3 


10 ... = .6 


rU . 






= .0006 


12 






= .8 


A 






= .OOI 


i5 






= 1.0 


1 

32 






= .002 


20 






= 1.2 


1 
T6 






= .004 


30 






= 2.0 


T2 






= -005 


60 






= 4.0 


1 
8 






= .008 


120 






= 8.0 


1 

6 






= .OI 


240 






= 15-0 


1 
4 






= .OI5 


480 






= 3°-° 


1 
3 






= .02 


Ounces 








I 






= .06 


2 






= 60.0 


2 






= .12 


4 






= 115-° 


3 






= .2 


6 






= 170.0 


4 






• = .25 


8 






= 230.0 


5 






• = -3 


IO 






= 280.0 


6 






= -4 


15 






= 420.0 


8 






= -5 


20 






. = 568.0 



CENTIGRADE AND FAHRENHEIT SCALES. 



643 



CENTIGRADE AND FAHRENHEIT SCALES. 

To convert Fahrenheit into Centigrade, subtract 32, multiply the 
remainder by 5, and divide the result by 9. 

To convert Centigrade into Fahrenheit, multiply by 9, divide by 
5, and add 32. 

The following table shows the relation of degrees Fahrenheit to 
Centigrade 



Centigrade 






Fahrenheit 


Centigrade 






Fahrenheit 


no . . . 230 


37 • 98.6 


IOO 






212 


3 6 -5 






97-7 


95 






203 


36 






96.8 


90 






194 


35-5 






95-9 


85 






185 


35 






95-o 


80 


- 




I76 


34 






93- 2 


75 






167 


33 






91.4 


70 






158 


3 2 






89.6 


65 






149 


3 1 






87.8 


60 






I40 


30 






86 


55 






I3.I 


25 






77 


50 






122 


20 






68 


45 






JI 3 


IS 






59 


44 






III. 2 


10 






5° 


43 






IO9.4 


+ 5 






41 


42 






IO7.6 









3 2 


4i 






IO5.8 


- 5 






2 3 


40.5 






IO4.9 


— 10 






14 


40 






IO4.O 


— 15 






+ 5 


39-5 






IO3. 1 
102.2 


— 20 






-4 


39 


o-54° i° 


38.5 






• ioi-3 


1 = 1.8 


38 






100.4 


2 3.6 


37-5 






99-5 


3 






5-4 



INDEX 



Abasia, 36 

Abdomen, physical examination of, 
227 

tenderness of, 73 

topography and regional divis- 
ions, 223, 224 

examination, 226 
Abdominal crises, 272 

examinations, technic of, 226 

measurements, 88 

organs, diseases of, 223 

pain, 63, 64, 65, 66 

reflex, 529 
Abducens, lesions of, 563 

paralysis, 542 
Abnormal breath sounds, 101 

percussion notes, 96, 97 

variation in temperature, 51 
Abortive typhoid, 432 
Abscess, 586 

of liver, pysemic, 297 

of lung, 162 

mediastinal, 164 

retropharyngeal, 120 
Absence of sweating, 10 
Absent pulse, 171 
Acarus scabiei, 506 
Accidental murmurs, 185 
Accelerated breathing, 76 
Accommodation, reaction to, 553 
Accumulation, fecal, 286 
Acetic acid, heat and brine test, 329 

test for, 239 
Acetone in urine, 338 
Achilles jerk, 528 
Achoria, 247 
Achylia, 255 

Achylia gastrica simplex, 254 
Acid, diacetic in urine, 338 

ow butyric in urine, 338 

uric, in urine, 321 

Acidity, normal, 245 

of stomach contents, 241, a \;, 
244, 245 

42 645 



Acids, mineral, poisoning, 635 
Aconite, poisoning by, 635 
Acromegalia, 421 
Acromegaly, 421 

definition, 421 

historical note, 421 

etiology, 421 

symptoms, 421 

differential diagnosis, 424 

spade hand of, 25 
Acroparesthesia, 609 
Actinomycosis, 487 

pulmonary, 166 
Active congestion of lungs, 149 

life, influence of, 41 
Acute anterior poliomyelitis, 599 

bronchitis, 123 

appendicitis, 288 

catarrhal dysentery, 281 

congestion of kidney, 356 

congestive broncho-pneumonia, 
146 

coryza, 116 

cvstitis, 369 

disseminated broncho-pneumo- 
nia, 146 
5seminat< 

esophagitis, 309 

farcy, 487 

febrile delirium, 55 

febrile polyneuritis, 605 

fermentative diarrhea, 279, 2S0 

fibrinous pleurisy, 132 

gastritis, 261 

glanders, 487 

gout, joints in, 27, 2S 

hemorrhagic pancreatitis, 205 

hepatitis, 207 

1 [odgkin's disease, 409 

ileo colitis, 281 

intestinal indigestion, 279 

intestinal obstruction, :oi 

pain in, (v| 
laryngitis, 121, 



646 



INDEX. 



Acute miliary tuberculosis, 153 
cause, 153 

morbid anatomy, 153 
symptoms, 153 
physical signs, 153, 154 
course, 154 
myocarditis, 218 
myxcedema, 418 
nephritis, 356 
peritonitis, 291 
pharyngitis, 119 
pneumonic tuberculosis, 154 
lobar form, 154 
broncho-pneumonic form, 154 
poisoning, 635 
prostatitis, 370 
rheumatism, 507 

joints in, 27 
rhinitis, 116 
specific dysentery, 281 
suppurative pancreatitis, 296 
swellings of lips, 20 
tonsillitis, 121 
transverse myelitis, 595 
cause, 595 
symptoms, 596 
differential diagnosis, 598 
tropical dysentery, 281 
tuberculosis, 153 
tuberculous meningitis, 576 
tuberculopneumonic phthisis, 

154 
yellow atrophy, 308 
Addison's disease, 414 
definition, 414 
etiology, 414 
pathology, 414 
symptoms, 414 
diagnosis, 415 
differential diagnosis, 415 
prognosis, 416 
coloration of skin in, 7 
Adenoids, post nasal, 119 
Adductor jerk, 530 
Adhesions, pleuritic, 135 
Adhesive pericarditis, 216 
Adventitious breath sounds, 104 
Afebrile conditions, 53 
Age estimation, 38 

influence of, 38 
Agglutination reaction, 395 
test, Widal's, 434 
technic, 435 
value, 436 
Agonal temperature, 51 



Agraphia, 29, 535 
Ague, 448 

cake, 451 
Ailment, history of present, 49 
Ailments, misnamed, 49 
Air-content of sputum, 112 
Air-hunger, 77 
Alae, working. 19 

chest, 86 
Albumin in urine, 324 

in stomach- contents, 240 
Albumin, tests for, 326 

heat and nitric acid test, 327 
nitric acid contact test, 327 
acetic acid, heat and brine 

test, 329 
potassium ferrocyanide test, 

3 2 9 
Robert's test, 329 
Spiegler's test, 329 
trichloracetic acid test, 329 
quantitative tests, 330 
Esbach's, 330 
centrifugal method, 330 
Albumin-content of sputum, 113 
Albuminometer, Esbach's, 330 
Albuminoses, 325 
test for, 325 
Albuminuria, significance of, 324, 

326 
Alcopeptone in urine, 318 
Alcohol, influence of, 40 
Alcoholic meningitis, 577 
neuritis, 490 
tremor, 30 
Alcoholism, 489 
chronic, 489 
visceral alterations, 489 
neuritis, 490 
delirium tremens, 490 
Alexia, 536 
Alizarin solution, 243 
Alkalinity of blood, determination 

of, 396 
Allen's test, 334 
Alopecia, 5 

Alterations of extremities in disease, 
26 
in pupils, significance of, 58 
of voice and speech in disease, 
28 
Alternatives in heredity, 46 
Amaurosis, 556 
Amaurotic family idiocy, 595 
Amblyopia, 556 



^ 



INDEX. 



647 



Amoebic dysentery, 281 
Amidulin, 240 
Amimia, 29, 535 
Ammonia in urine, 324 
Amnesia, auditory, 30 

visual, 29 
Amnesic aphasia, 536 
Amoeba dysenteriae, 281, 494 
Amount of sputum, 113 
Amphoric breathing, 102 

percussion note, 97 
Amyloid kidney, 365 

liver, 305 
Amyotrophic lateral sclerosis, 600, 

601 
Anachlorhydria, 246 
Analysis of common symptoms, 49 
Anarthria, 29, 535 
Anasarca, 10 

Anatomy of chest, topographical, 80 
Anchovy sauce sputum, 112 
Anchylostoma duodenale, 502 
Anaemia, 377, 398 

types, 398 

color of skin, 398 

muscular weakness, 399 

temperature in, 399 

gastrointestinal symptoms, 400 

respiratory symptoms, 401 

circulatory symptoms, 401 

nervous symptoms, 401 

general symptoms, 401 

eye symptoms, 401 

etiology, 401 

varieties, 402 

prognosis, 407 

of the cord, 589 

cerebral, 571 

of ear, 19 

feigned, 624 

pernicious, 403 

splenic, 404 
Anaemias, differential diagnosis of, 

406 
Anaemic headache, 67 

murmurs, 184, 400 

pulsation, 210 
Anaesthesia, 537 

dolorosa, 539, 598 
Anaesthetic Leprosy, 483 
Aneurism, decubitus in, 34 

of the heart, J20 

thoracic, 204 

murmurs in, 208 
Angio neurotic edema, 10, ex, 6og 



Angina pectoris, 222 
symptoms, 223 
associated lesions, 223 

feigned, 624 
Angle of Louis, 80 
Angulus Ludovici, 80 
Anidrosis, significance of, 10 
Aniline, influence of, 43 
Ankylostomiasis, 501 
Ankle clonus, 529 

Anomalies of heart, congenital, 199 
Anopheles, 450 
Anosmia, 551 
Anorexia, 247 

nervosa, 254 
Antemortem recession of tempera- 
tures, 57 
Anthracosis, 165 
Anthrax, 483 

symptoms, 483 

varieties, 484 

diagnosis, 484 

prognosis, 484 
Anthrax bacillus, 483 
Aorta, aneurism of arch of, 208 

boundaries, 83 
Aortic aneurism, differential diag- 
nosis of, 210 

isthmus, persistent, 199 

regurgitation, 195 

stenosis, 192 
Aortitis, decubitus in, 34 
Apepsia, 254 
Apex beat, location of, 84, 177 

displacement of, 178 

obscuration of, 178 
Apex movement, 161 
Apex retraction, 87 
Aphasia, motor, 29, 535, 584 

sensory, 29, 535, 584 
Aphcmia, 29, 535 
Aphonia, 20, 546 

feigned, 624 
Aphthous stomatitis, 21 
Apoplexy, 581 

hereditary tendency, -t; 

pulmonary, 161 

Appearance of eyes, 1 7 

of eyelids, 17 
of head in disease, 16 
Appendicitis, oj 
acute, 288 

prevalence, »88 
etiology, 288 
symptoms, 289 



6 4 8 



INDEX. 



Appendicitis, physical signs, 289 
perforation, 290 
differential diagnosis, 290 
prognosis, 291 

chronic, 291 

decubitus in, 34 
Appetite, alterations in, 247 
Apropia, 29, 536 

Aran-Duchenne type, muscular at- 
rophy, 601 
Arch of aorta, aneurism, 208 
Arcus senilis, 18 

Areas, auscultation, of heart, 183 
Argyll Robertson pupil, 553, 588, 590 
Argyria, 7 
Argyrosis, 7 

Arm, alterations in disease, 26 
Arrhythmia of pulse, 170 
Arsenic, influence of, 43 

poisoning by, acute, 636 
Arsenical poisoning, chronic, 492 
Arsenical melanosis, 7 
Arterial pulse, 167 
Arterio-sclerosis, 221 

definition, 221 

morbid anatomy, 221 

etiology, 222 

symptoms, 222 
Arterio-sclerotic abdominal crises, 

272 
Arthritic purpura, 411 
Arthritis deformans, 510 

general progressive, 511 

fingers in, 25 

joints in, 28 
Arthropathies in organic nervous 

diseases, 28 
Arthrosia podagra, 509 
Ascaris lumbricoides, 500 
Ascites, 12 

Ascitic fluid, character of, 13 
Ascitic wave, 12 
Asiatic cholera, 441 

definition, 441 

historic note, 441 

etiology, 441 

morbid anatomy, 442 

symptoms, 442 

prognosis, 443 

diagnosis, 443 
Aspergillomycosis, pulmonary, 166 
Aspiration in pleural effusions, 135 
Asthenic bulbar paralysis, 604 
Asthenic fever, 55 
Asthma, decubitus in, 34 



Asthma, feigned, 624 
spasmodic, 128 

definition, 128 

etiology, 128 

exciting causes, 128 

theories as to causation, 129 

time of attack, 129 

aurae, 129 

symptoms, 130 

physical signs, 130 

prognosis, 130 
Atasia, 36 
Ataxia, 537 

hereditary. 592 
Ataxic aphasia, 535 

gait, 35> 59 1 

paraplegia, 592 
Atelectasis, 148 

definition, 148 

etiology, 148 

diagnosis, 149 
Atheroma, 221 
Athetoid movements, 32 
Athyrea, 416 
Atony, gastric.. 255, 257 
Atrophic cirrhosis, 301 

rhinitis, 117 
Atrophy, acute yellow, 308 

of ball of thumb, 548 

of the extremities; feigned, 624 

of tongue, 23 

gastric, 254 
Atropin, poisoning by, 636 
Attitude, 33 

of patient in abdominal exam- 
ination, 226 

of patient and physician for 
chest examination, 85 

of patient during auscultation, 
100 
Auditory amnesia, 30 

aphasia, 536 

nerve, lesions of, 564 
Aura, 610 * 

Aural discharges, 19 
Auscultation, 98 

technic, 100 

varieties, 99 
Auscultatory percussion, 92 

of stomach, 235 
Auscultatory phenomena, basis of, 

98 
Auscultatory pulmonary areas, 100 
Autohypnotism, 617 
Axis cylinder, 512 



^ 



INDEX. 



649 



Babinski's toe reflex, 529 
Bacillus anthrax, 483 

Boas-Oppler, 252 

cholera, 441 

Eberth, 427 

influenza, 439 

of Kitasato, 443 

Klebs-Loffler, 463 

of Koch, 441 

leprae, 482 

mallei, 487 

of Pfeiffer, 439 

pestis, 443 

tetani, 486 
Back, alterations in disease, 27 
Bacteriuria, 343 
Balantidium coli, 494 
Bamberger's disease, 424 
Barkeepers, affections common to, 42 
Barking cough, 109, no 
Barlow's disease, 413 
Barrel chest, 86, 126 
Basedow's disease, 419 
Basis of diagnosis, 1 
Basis, purin, 322 
Basophiles, 386 
Basophilic erythrocytes, 388 
Beat, apex, 177, 178 
B*ed bug, 507 
Beefy tongue, 22 
Belching, 252 
Bell's mania, 55 

palsy, 564 
Belly, poached-egg, 303 
Bence- Jones' proteid in urine, 326 
Beri-beri, neuritis in, 606 
Biceps jerk, 528 
Biermer's sign, 98 
Bile-ducts, acute catarrh of, 305 
Bile in urine, 333 

nitric acid test, 333 

Marechalt's test, 333 

Haycraft's test, 333 
Bilharzia haematobia, 494 
Biliary calculi, 278, 305 

passages, diseases of, 2q6 
Biot's respiration, 7S 
Bilious headache, 67 
Bilocular stomach, 260 
Birth palsy, 594 
Black death, 443 

fever, 457 
Bladder, acute inflammation of, 369 

chronic inflammation of, 369 

tuberculosis of, 370 



Bladder, tumors of, 370 
Bleeder's disease, 412 
Blind terms, 46 
Blindness, feigned, 624 
Blood in bubonic plague, 444 

in cholera, 442 

in malaria, 450 

in urine, 331 
tests, 332 
sources of, 332 

in urinary sediment, 342 

in vomit, 250 
tests for, 250 
Blood casts, 347 
Blood-cells, 385 

red, 385 

white, 386 
Blood-cell count, 388 
Blood-count in cerebro-spinal men- 
ingitis, 574 
Blood, changes in, 376 

changes in pneumonia, 141 

diseases of, 398 

examination of, 376 

for examination, how to obtain, 
378 
Blood-plates, counting, 396 
Blood-pressure, determination of, 172 

abnormally high, 173 

abnormally low, 173 

technic for examining, 378 
Blood vessels, 167 
Blue line on gums, significance of, 

23, 49i 
Boas-Oppler bacillus. 252 
Boas' test breakfast, 238 
Bodies, Negri, 486 
Borders, lung, 95 
Boring pain, 62 
Bothriocephalus latus, 497 
Bowels, diseases of, 274 

inflammation of, 279 
Brachial plexus paralysis, 540 
Brachio-crural hemiplegia, 543 
Bradycardia, 169 
Bradycardia, 169 
Brain, diseases of, 568 

abscess headache, 07 

tumors, 57S 
varieties, 578 
symptoms, 570 

etiologic factors, 570 
focal symptoms, 580 

tumor headache. 07 

Brazen cough, 1 10 



J 



650 



INDEX. 



Break-bone fever, 445 
Breakfast, test, 238 
Breath, odor of, 20 

shortness of, 76 

in stuporous conditions, 60 
Breath sounds, abnormal, 98, 100, 101 

normal, 98, 100, 101 

adventitious, 104 
Breathers, mouth, 119 
Breathing, amphoric, 102 

cavernous, 102 

Cheyne-Stokes, 79, 351 

cog-wheel, 101 

broncho-vesicular, 102 

glottic, 102 

puerile, 10 1 

suppressed, 101 

tubular, 102 

vesicular, 101 
Bright's disease, color of skin in, 6 

headache, 67 
Brittle nails, 26 
Broca's convolution, 535 
Bromine, influence of, 43 
Bronchi, foreign bodies in, 127 
Bronchial breathing, 101 

glands, diseases of, 163 
symptoms, 163 

voice, 103 
Bronchiectasis, 127 

causes, 127 

physical signs, 128 

prognosis, 128 
Bronchitis, etiology, 123 

morbid anatomy, 124 

symptoms, 124, 125 

physical signs, 124, 125 

prognosis, 125 
acute, 123 
capillary, 144 
chronic, 123, 125 
diseases associated with, 125 
Bronchophony, 103 
Broncho-vesicular breathing, 102 
Broncho-pneumonia, 144 

definition, 144 

etiology, 144 

morbid anatomy, 145 

chief divisions, 145 

sub-divisions, 146 

symptoms, 146, 147 

physical signs, 147 

complications, 148 

termination, 148 

forms of, 146, 147, 148 



Bronze John, 446 
Brown-Sequard paralysis, 526 

syndrome, 595, 598 
Bruit de diable, 400 
Bruit de pot fele, 97 
Bruit, systolic, 208 
Bubbling rales, 105 
Bubonic plague, 443 

definition, 443 

historic data, 443 

etiology, 443 

morbid anatomy, 444 

symptoms, 444 

varieties, 444 

diagnosis, 445 

mortality, 445 
Buccal cavity, 20 

alterations in secretions of, 21 

eruptions in, 20 

pigmentation of, 20 
Buccal psoriasis, 23 
Bulbar paralysis, 567 
Bulimia, 247 
Bulging, precordial, 179 
Bullet bubo, 476 
Burdach, column of, 518, 521 
Butyric acid, test for, 239 

Cadaveric emanation, 20 
Caisson disease, 570 
Calcium carbonate in urinary sedi- 
ment, 341 

oxalate in urinary sediment, 341 
Calculi, biliary, 278, 305 

feigned, 628 

pancreatic, 278, 296 

urinary, 371 
Callosities associated with certain 

occupations, 45 
Cancer cells, 252 

feigned, 625 

hereditary tendency, 47 

of peritoneum, 295 
Candle-test, 562 
Cantharides, poisoning by, 636 
Capillary bronchitis, 144 

pulse, 172, 196 
Capsular cirrhosis, 301, 302 
Caput medusae, 14, 301, 303 
Carbolic acid poisoning, 637 
Carbon bisulphide, influence of, 43 
Carcinoma, cerebral, 580 

esophageal, 310 

nasal, 118 

pancreas, 296 



I 



INDEX. 



651 



Carcinoma of stomach, 269 
Cardiac area, percussion, 94 
in aortic regurgitation, 196 
superficial, 82 
edema, 11 

disease, color of skin in, 6 
dulness, 179 

plexus, involvement of, 567 
Cardio-vascular alternatives, 47 
Cardio-respiratory murmur, 185 
Case-taking, preliminary remarks 

on, 1 
Casts in urinary sediment, 344 
Casts, significance and association 

of, 347 
Catalepsy, 32, 614, 634 

feigned, 626 
Cataract, 18 
Catarrh, chronic, 116 

dry, 117 

of the bile-ducts, acute, 305 

of the mouth, simple, 21 

stomach, 261 
Catarrhal fever, 438 

jaundice, 305 

jaundice, chronic, 305 

pneumonia, 144 
Causes of cyanosis, 7 
Causes of fever, 53 
Caustic alkalies, poisoning, 637 
Cavernous breathing, 102 
Cells, blood, 385 

cancer, 252 

in urine, 343 
Centigrade scale, 643 
Central vomiting, 248 
Centrum semi-ovale, 541 
Cercomonas hominis, 494 
Central scotomata, 556 
Cerebellar hereditary ataxia, 593 
Cerebellum, lesions of, 543 
Cerebral abscess, 586 

symptoms, 587 

anaemia, 571 

concussion, feigned, 626 

congestion, 571 

edema, 571 

embolism, 581 
Cerebral hemorrhage, 581 

causes, 581 

premonitory symptoms, 58a 

symptoms of attack, e8a 

residual symptoms, 583 

localizing symptoms, 584 

differential diagnosis, 584 



Cerebral hemorrhage and e mbolism 

differential diagnosis, 585 
Cerebral thrombosis, 571, 581, 586 
Cerebral tracts, symptomless, 539 
Cerebro-spinal meningitis, epidemic, 

573 

cause, 573 

symptoms, 573 

complications, 574 

diagnosis, 574 

Kemig's signs, 575 

lumbar puncture, 575 

prognosis, 576 
Cervico-brachial neuralgia, 69 
Cervico-occipital neuralgia, 69 
Cestodes, 496 
Chalicosis, 165 
Chancre, 476 
Change in general appearance as 

aid to diagnosis, 5 
Changes in chest outline in dyspnoea, 

. 78 

in gums in disease, 23 
Character of ascitic fluid, 13 
Character of pain, significance of, 61 
Charbon, 483 
Charcot's joints, 28, 591 
Chemic examination of urinary cal- 
culi, 371 
Chest deformities, 87 
Chest, examination of, 85 

general form, 86 

measurements, 88 

movements, 88 

normal, 86 

percussion of, in disease, 96 

regional divisions of, 80, 81 

tenderness of, 73 

topographical anatomy of, 80 

X-ray examination of, 106, 107, 
108, 109 
Cheyne-Stokes breathing, 70, 351 
Chicken-pox, 473 

temperature in, 56 
Chloasma gravidorum, 7 
Chloral hydrate, poisoning, 637 
Chlorides, urinary, 32a 
Chlorine, influence of, 43 

Chlorosis, 40.' 

blood-findings, 40a 

pathogenesis, 40a 

Egyptian, 501 
Choked disk, 557, 571) 
Cholecystitis, acute, 305 

Cholelithiasis, 305 



652 



INDEX. 



Cholelithiasis, obstruction of com- 
mon duct, 307 

obstruction of cystic duct, 307 

general comment, 307 
Cholera, Asiatic, 441 

infantum, 280 
Chorea, 612 

symptoms, 612, 613 

course, 613 

differential diagnosis, 614 

feigned, 626 

gait of, S5 

joints in, 28 

pandemic, 614 
Choreic gait, 35 
Chromium, influence of, 43 
Chronic adhesive pericarditis, 216 

alcoholism, 489 

anterior poliomyelitis, 600 

appendicitis, 291 

arsenical poisoning, 492 

bronchitis, 123, 125 

bronchitis, diseases associated 
with, 125 

catarrh, 116 

cystitis, 369 

diffuse nephritis with exuda- 
tion, 364 

dysentery, 282 

endocarditis, 215 

gastric catarrh, 261 

gastritis, 261 

interstitial nephritis, 361 

interstitial pneumonia, 164 

intestinal obstruction, 284 

intussusception, 285 

lead-poisoning, 490 

laryngitis, 122 

malaria, 452 

meningitis, 578 

myocarditis, 218 

passive congestion of the kid- 
ney, 355 

pancreatitis, 296 

parenchymatous nephritis, 359 

peritonitis, 293 

pharyngitis, 119 

pleurisies, 136 

prostatitis, 370 

rheumatism, joints in, 28 

rhinitis, 116 

tonsillitis, 121 
Chronic ulcerative tuberculosis, 155 

definition, 155 

pathologic anatomy, 155 



Chronic ulcerative tuberculosis, 

symptoms, 156 

physical signs, 159 

comment, 160 
Chylous ascites, 13 

pleurisy, 166 
Chyluria, 503 
Cilio-spinal reflex, 527 
Cimexlectularius, 507 
Cirrhosis, atrophic, 301 

capsular, 301, 302 

Hanot's, 301, 304 

hypertrophic, 301, 304 

Laennec's, 301, 302 

of the liver, 301 

syphilitic, 301, 304 
Cirrhotic kidney, 361 
City, influence of, 41 
Clark, column of, 518 
Classification of nervous disease, 525 
Claw hand, 550 
Clinical valvular areas, 84 
Clonus, 529 
Clubbed fingers, 25 
Coagulation time, 396 
Coated tongue, 22 
Cocain habitue, color of, 7 
Cocain, influence of, 40 

poisoning, 637 
Coffee, influence of, 40 
Cog-wheel breathing, 101 
Coin sound, 92, 98, 104 
Colchicum poisoning, 637 
Colic, 62 

colon, 63 

gall stone, 63 

gastric ulcer, 64 

lead, 64 

renal, 63 
Colicky pain, 62 
Collapse in cholera, 442 

significance of, 79 
Collateral localized edema, 12 
Collateral nervous circulation, 14 
Colon colic, 63 
Color fields, 555 

Color of mucous membrane, signifi- 
cance of, 5 

of skin in anaemia, 398 

of skin in Bright's disease, 6 

of skin in cardiac disease, 6 

of skin, significance of, 5 

in stupor from various causes, 

59 
of sputum, in 



INDEX. 



653 



Color of urine, 313 

index of blood, 378 
Coloration of Addison's disease, 7 

in melano-sarcoma, 7 
Coma, 57 

diabetic, 374 

uremic, 352 

vigil, 57 
Comma bacillus, 441 
Common form broncho-pneumonia, 

147 
Compensation, 199 

alterations in, 200 
Complete incompensation, 202 

transverse spinal cord lesions, 

527. 

Complicating purpura, 411 

Complications of broncho-pneumo- 
nia, 148 

Compound granule cells, 344 

Compression myelitis, 595 

Concealed hemorrhage, 80 

Conditions associated with tremor, 

30 

simulating death, 634 
Conduction in motor areas, 512 

in sensory areas, 512 
Confluent smallpox, 469 
Congenital anomalies of the liver, 
296 

gastric stenosis, 273 

heart disease, 198 

hydrocephalus, 578 

syphilis, facies of, 4 
Congestion, cerebral, 571 
Congestion of lungs, 149 

active, 149 

passive, 149 

morbid anatomy, 149 

diagnosis, 150 
Congo-red paper, 239 
Conjugate deviation, 562 
Conjunctivitis, 558 
Conjunctival reflex, 527 
Consonating rales, 106 
Consumption, 151 

feigned, 626 

galloping, 154 

Constipation, 285 

Constitutio Lymphatica, 416 

Continuous fever, 52 

mental strain, influence of, .\2 

Contracted kidney, 361 

pupils, 58, 553 
Contractures, feigned, 636 



Convulsions, feigned, 627 

infantile, 33 

varieties, 59 
Convulsive movement, nature of, 59 

seizures, 31 

tic, 614 
Copper, influence of, 43 
Cord, anaemia of, 589 

embolism of, 590 

endarteritis of, 590 

thrombosis of, 590 
Corpuscles of Poggi, 387 
Corrigan pulse, 196 
Corneal opacities, 18 
Corpoliths, 278 

Corpora quadrigemina, lesions, 542 
Cortex, 539 
Cortical areas, 540 

lesions in deafness, 566 
Corrosive sublimate, poisoning, 638 
Coryza, acute, 116 
Cough, definition, 109, no 

varieties, no 

significance, 109 

types, no 

brazen, 207 
Country, influence of, 41 
Cover-glass preparations of blood, 

378 
Cracked-pot sound, 97 
Crackling murmur, 185 

rales, 105 
Cramp colics, 31 
Cramps, 31 

in cholera, 442 

varieties, 31 
Cranial nerves, involvement of, 551 
Cranio-tabes, 425 

head in, 16 
Creatinin, 319 
Cremasteric reflex, 529 
Crepitant rale, 105 
Crepitatio induz, 105 

redux, 105 
Crepitation, 105 

of the skin, 14 
Crescendo speech, 29 
Cretinism, .| 10 
Crises, 56, 140 

abdominal, 

Dietl's, 63, 306^ 366 

gastric, 27a 

pseudo, 57 

Visceral, UQ locomotor ataxia, 

591 



654 



INDEX. 



Critical discharges, 56 
Crossed-leg progression, 35 
Crossed tract, 516 
Cross eye, 561 
Croton oil poisoning, 637 
Croup, 77, 122 

true, 123 
Croupous pneumonia, 138 
Crura, lesions of, 542 
Cryptogenetic polycythemia, 408 
Cryoscope, Fontaine's, 353 
Cryoscopy, 352 
Curschmann's spirals, 112 
Cutaneous lesions, feigned, 627 
Curvature of spine, lateral, 27 
Cyanosis, 6 

causes of, 7 

of ear, 19 

of lips, 20 
Cyanotic polycythemia, 408 
Cylindroids, 348 
Cynauche maligne, 462 
Cystic tumors of liver, 300 
Cystitis, acute, 369 

chronic, 369 
Cyto-diagnosis, 396, 589 
Cysts, echinococcus, 300 

pancreatic, 296 

Dandy fever, 445 

Dare's haemoglobinometer, 383 

Davainea Madagascariensis, 498 

Deafness, 565 

Death, conditions simulating, 634 

Decubitus, ^t, 

Decubitus in typhoid, 431 

Defecation, 530 

Defective memory, 534 

Defervescence, 52 

Deformities of chest, general, 86 

Degenerations, 523 

Degeneration of heart muscle, 218 

Degenerative changes, sequence of, 

525 
Degeneration, reactions of, 531 
Delayed dentition, significance of, 

24 
Delirium, 534 

acute febrile, 55 

in pneumonia, 142 

tremens, 490 
Delusions, 534 

of grandeur, 588 
Dementia, paralytic, 587 
Dendrites, 512 



Dengue, 445 

definition, 445 

etiology, 445 

prognosis, 445 

symptoms, 445 
Dentition, alterations in, 24 
Dermatitis factitia, 627 
Description of illustration of tests of 
stomach contents, 242 ijj_^ 
Desquamations, 15 
Diabetes, odor of health in, 20 J 

hereditary tendency, 47 

insipidus, 376 

mellitus, 372 
Diabetic breath, 60 

coma, 374 
Diacetic acid in urine, 338 
Diagnosis, basis of, t 

definition of snap, 2 

by direct methods, 2 

by examination of gastric con- 
tents, 244 

by exclusion, 2 

by indirect methods. 2 

by inflation and liquid injec- 
tions, 66 

pulmonary, remarks on, 1 

scope of, 1 

therapeutic, 2 
Diagnostic import of fever, 52 
Diagnostic methods in pulmonary 

and cardiac disease, 84 
Diaphragm, Litten's phenomenon, 

88 
Diaphragmatic pleurisy, 132 

decubitus in, 34 
Diarrhea, critical, 56 

feigned, 627 

in typhoid, 432 
Diastole, 187 

murmurs in, 189 
Diastolic valvular murmur, charac- 
teristic symptoms of, 194 
Diastolic venous collapse, 176 
Diathesis, expression of, 4 
Diazc-reaction, 349 

Ehrlich's, 434 

limitations, 434 
Dicotophyme gigas, 504 
Dicrotic pulse, 171 
Diet, influence of, on acidity of gas- 
tric contents, 244 

test, Schmidt's method, 276 
Dietl's crisis, 63, 306, 366 
Differential blood count, 392 



INDEX. 



655 



Differential diagnosis of aortic aneu- 
rism, 210 
Differentiation of ascites, 13 
Digestive organs in fever, conditions 

of, 54 
Digital neuralgia, 70 
Dilatation of heart, 191 
Dilated pupils, 58 
Dilated stomach, 256 
Dimethyl-amido-benzol, 243 
Diminished resonance, 97 
Dinner, test, 239 
Diphtheria, 462 

definition, 463 

distribution, 463 

morbid anatomy, 463 

symptoms , 463 
" complications, 465 

differential diagnosis, 465 

prognosis, 465 
Diphtheritic dysentery, 281 
Diplococcus pneumoniae, 145 
Diplococcus of Weichselbaum, 573 
Diplopia, 562 
Direct tract, 516 
Direct diagnosis, 2 
Direct sensory tract, 517 
Discharges, aural, 19 
Disease, Addison's, 414 

Bamberger's 424 

Barlow's, 413 

Basedow's, 419 

caisson, 570 

Erb's, 594 

Flajani's, 419 

foot and mouth, 456 

Friedreich's, 592 

G16nard's, 287 

Gower's, 592 

Graves', 419 

Hodgkin's, 408 

Landry's, 599 

Little's, 595 

Marie's, 421, 593 

Meniere's, 56^ 

Osier's, 408 

Paget's, 424 

parasitic, 494 

Parkinson's, 615 

Parry's, 419 

Raynaud's, 60S 

Rossbach's, 245, 246 
SchGnlein's, .1 1 1 
Teichmann's, 245, 246 
Tomsen's, 604 



Disease, vagabond's, 507 

Von Recklinghausen's, 607 

Weil's, 308 

wool-sorter's, 483 
leucocytosis in, 393 
outward signs of, 3 
Diseases due to occupation, 41 

infectious, 427 

of abdominal organs, 223 

of biliary passages, 296 

of the blood, 398 

of blood and ductless glands, 376 

of brain, 568 

of the bronchi, 123 

of bronchial glands, 163 

of the esophagus, 309 

of the intestines, 274 

of the kidney, 310 

of the larynx, 115, 121 

of the liver, 296 

of the muscles, 604 

of nervous system, 512 

of nose, 115 

of pancreas, 295 

of pharynx, 115, 119 

of respiratory tract, 123 

of spinal cord, 568 

of thoracic viscera, 80 

of the tonsils, 121 
Displacement of heart in pleural ef- 
fusion, 134 
Disseminated sclerosis, 570 

tremor in, 31 
Distomum lanceolatum, 495 
Dittrich's plugs, 112 
Diurnal variation in temperature, 51 
Diverticula, esophageal, 309 
Divisions of chest, regional, So, Si 
Doremus urometer, 321 
Dolor cordis, 222 
Dracontiasis, 504 
Dracunculus mcdinensis, 504 
Dress as an aid to diagnosis, 5 
Dropsy, 10 

feigned, 627 
Drug eruptions, 15 

habit, 40 

headaches, 07 

Drunkards, 489 

catarrh, 269 
Dry catarrh, 1 1 7 

cough, tio 

rye, significance oi, [8 

rales, k\| 

skin, significance of, \o 



6 5 6 



INDEX. 



Dryness of mouth, 21 
Ductless glands, changes in, 376 
Ductus arteriosus, persistent, 199 
Dull pain, 62 
Dulness, 93 

liver, 82 

shifting, 82 
Dumb ague, 451 
Duodenal ulcer, 267, 286 
Duration of percussion sounds, 93 
Dysentery, 280 

etiology, 281 

varieties, 281 

symptomatology, 281 

differential diagnosis, 282 

mortality and general comment, 
282 
Dyspepsia, 253 

feigned, 627 
Dyspeptic headache, 67 
Dyspeptic symptoms, general, 266 
Dyspnoea, 76 

changes in chest outline in, 78 

on exertion, 77 

simulated, 628 

varieties, 77 
Dysuria, 312 

Ear, 19 
Earache, 19 
Eberth's bacillus, 427 
Ecchymoses, 14 

Echinococcus cysts of liver, 300 
Echoing resonance, 104 
Eczema of tongue, 23 
Edema, 10 

cerebral, 571 

collateral localized, 12 

of glottis, 122 

varieties of, 1 1 
Effects of poisoning on tongue, 23 
Effusion, pleurisy with, 133 
Effusions, 12 
Egophony, 103 
Egyptian chlorosis, 501 
Ehrlich's diazo-reaction, 349, 434 

triacid stain, 381 
Einhorn's saccharometer, 335 
Electrical reactions, significance of, 

53i 

tests, 531 
Elephantiasis, 503 
Emanation, cadaveric, 20 
Embolism, cerebral, 581 

intestinal, 287 



Embolism, pulmonary, 161 

of spinal cord, 590 
Emotional jaundice, 9 
Emphysema, varieties, 125 

symptoms, 126 

physical signs, 126, 127 

chest in, 86 

subcutaneous, 14 

and bronchitis, 125 
Empyema, symptoms, 135 
Endarteritis of spinal cord, 590 
Endocarditis, 213 

definition, 213 

varieties, 213 

etiology, 213 

subacute, 214 

ulcerative, 214 

chronic, 215 
End reactions, 243 
Enlargement of the spleen, 231 
Enophthalmos, 18 
Enteralgia, 283 
Enteric fever, 427 
Enteritis, 279 

chronic, 280 
Enteroliths, 277 
Enteroptosis, 287 
Eosinophiles, 386 
Eosinophilia, 393 
Ephemeral fever, 51 
Epidemic catarrhal fever, 438 

cerebrospinal meningitis, 573 

parotitis, 459 
Epigastric reflex, 529 
Epilepsy, 610 

divisions, 610 

grand mal, 610 

petit mal, 611 

Jacksonian, 611 

equivalents, 611 

differential diagnosis, 611 

feigned, 628 
Epistaxis, 118 
Epithelioma of lips, 20 
Epithelial casts, 347 
Epithelium in urinary sediment, 343 
Erb-Goldflam's syndrome, 604 
Erb's syphilitic spinal paralysis, 594 
Erb, motor points of, 532, 533 
Erb's type, 550 
Ergotism, 492 
Erosions, gastric, 268 
Eructation, 252 
Eruptions, drug, 15 . 
Eruption in leprosy, 482 



INDEX. 



657 



Eruption in measles, 458 

in scarlet fever, 460 

simulating scarlatina, 462 

in smallpox, 468 

in syphilis, 477 

in varicella, 473 
Erysipelas, 481 

definition, 481 

etiology, 481 

symptoms, 481 

diagnosis, 481 
Erythroblasts, 387 
Erythrocytes, 385 
Erythrocytic forms, abnormal, 387 

staining reaction, abnormal, 387 
Erythrodextrine, 241 
Erythromelalgia, 609 
Eshach's albuminometer, 330 
Estivo-autumnal fever, 451 

Plasmodium, 450 
Esophageal, carcinoma, 310 

spasm, 310 

stricture, 309 
Esophagitis, acute, 309 
Esophagus, diseases of, 309 
Ethmoiditis, necrosing, 117 
Etiologic factors in nervous diseases, 

512 
Eustrongylus gigas, 504 
Ewald's test breakfast, 238 
Examination of abdomen, physical, 
227 

for aphasia, 536 

of blood, 376 

of chest, 85 

of gastric contents, 237 

of great blood vessels, 177 

of heart, 177 

of the kidneys, physical, 231 

of liver, physical, 228 

of muscles, 531 

of stomach, physical, 233 

of urinary sediments, 339 

of spleen, physical, 230 

of urine for tubercle bacilli, 348 

X-ray of chest, 106, 107, ioS, 109 
Exanthems, 55 
Excessive heat, influence of, 44 

Exclusion, diagnosis by, 2 

Exophthalmos, iS 
Exophthalmic goitre, 419 
definition, .| 10 

etiology, 419 

symptoms, .1 10, 420 
tremor in, 30 



Expansile pulsation, 206, 207 
Expiration, prolonged, 10 1 
Exposure to infection, influence of, 

48 
Expression, facial, 4 

in acute kidney disease, 6 
in chronic kidney disease, 8 
Extra-meningeal hemorrhage, 569 
External pachymeningitis, 569 
External signs of disease, 3 
Extremities, alterations in disease, 

26 
Eye diseases, feigned, 628 
Eye, dry, 18 
moist, 18 

motor nerves of, 560 
reflexes, 553 
symptoms, 552 
of anaemia, 401 
in exophthalmic goitre, 419, 

420 
of chronic interstitial nephri- 
tis, 363 
Eyes, 58 

appearance of, 17 
in stupor, 58 
Eye-strain headache, 67 
Eyelids, appearance of, 17 

Facial expression, 4 

nerve, lesions of, 563 

hemiatrophy, 17, 609 

paralysis, 564 

spasm, 564 

tremor, 30, 31 
Facies, 4 

of acute Bright's disease, 6 

of cholera, 442 

of chronic Bright's disease, 8 

of congenital syphilis, 4 

of diatheses, 4 

of gastric cancer, 4 

of general paresis, 4 

of malingering, 4 

of melancholia, | 

of sexual abuse, | 

of syphilis in adults, 5 
Faciola hepatica, 405 
Fahrenheit scale, 643 

Faintness, sensation of, 74 



" Fals 



" 6 



Family history, influence oi, 46 
Farcy, 4.87 
Farcy buds, 487 
Fastigium, 59 



A 



6 5 8 



INDEX. 



Fatigue neuroses, 42 

Fats in urine, tests for, 314 

Fatty ascites, 13 

casts, 347 

renal cells, 344 
Fawn-colored skin in kidney disease, 

6 
Fecal accumulation, 286 

impaction, 65 
Febrile delirium, acute, 55 

jaundice, acute, 308 

types, 52 
Feces, collection of specimen, 274, 

microscopic examination, 275 

tests, 275, 276 

inference from tests, 276 

concretions in, 276, 277 
Fehling's test, S33 
Feigned states, common, 624 
Fermentation test, 335 
Festinating gait, 36 
Fetid stomatitis, 22 
Fever and ague, 451 

black, 457 

break-bone, 445 

catarrhal, 438 

dandy, 445 

diagnostic import of, 52 

enteric, 427 

ephemeral, 51 

feigned, 628 

hay, 118 

lung, 138 

Malta, 454 

method of detection of, 49 

miliary, 456 

milk, 456 

mode of onset and terminations, 

5 6 
mountain, 456 

phenomena of, 54 

relapsing, 452 

spotted, 573 

scarlet, 460 

types of, 52 

trypanosome, 505 

typhoid, 427 

typhus, 453 

urine, 313 

varieties of, 50 

yellow, 446 

Filaria Bancrofti, 502 

diurna, 502 

nocturna, 502 



Filaria perstans, 502 

medinensis, 504 
Filariasis, 502 

morphology, 503 

symptoms. 503 
Fibrillary fiickerings, 31 
Fibrinous casts, 347 
Fibrinuria, 314 
Fibroid phthisis, 164 
Fictitious wounds, 628 
Finger-nails, alterations in disease, 25 
Fissures of tongue, 23 
Fistula, feigned, 628 
Flagellata, 494 
Flajani's disease, 419 
Flatness, 93, 97 
Flatulence, 252 
Flea, 507 

Flint murmur, 196 
Floating kidney, 365 
Flood fever, 456 
Florid face, significance of, 7 
Fluid, character of acetic, 13 
Fluoroscope in thoracic aneurism, 

204 
Fluoroscopic methods, 89 

signs, significance of, 109 
Fluoroscopy in pleuritic adhesions, 

136 

in pleurisy with effusion, 134 

of stomach, 233 

in tuberculosis, 157, 158 
Flukes, 494 
Flushing, morbid, 74 

significance of unilateral, 8 
Foot and mouth disease, 456 
Focal symptoms of brain tumors, 580 

cortex, 580 

cerebellum, 580 

corpora quadrigemina, 581 

crus cerebri, 581 

pons, 581 

internal capsule, 581 

optic thalamus, 581 
Follicular dysentery, 281 

stomatitis, 21 
Fontaine's cryoscope, 353 
Fontanelles, persistent, 425 
Food poisoning, 492 

remnants, 275 
Foot drop, 594 
Foreign bodies in bronchi, 127 

in heart, 220 

in nose, nq 
Form of chest, general, 86 



INDEX. 



659 



Formaldehyde poisoning, 638 
Formes frustus, 420 
Formication, 73 
Fracture, simulated, 629 
Fremitus, alterations in, 90, 91 

laws of, 90 

method of detection, 90 

vocal, 90 
Frenzy, maniacal, 630 
Fresh blood, examination of, 379 
Frequency of pulse, 168 
Friction sounds, 106 
Friedlander's bacillus, 145 
Friedreich's ataxia, 592 

phenomenon, 97 
Frog-face, 5 
Frothy lips, 60 

sputum, 112 
Full pulse, 171 
Fundus changes in nephritis, 363 

oculi, 559 
Funnel breast, 87 

Gait, 33, 35 

ataxic, 591 
Gall-bladder, contracted, 307 

outline of, 225 

physical examination of, 229 
Gall-stones, 305 
Gall-stone colic, 63 
Galloping consumption, 154 
Gangrene of lung, 162 
Gangrenous pancreatitis, 296 

stomatitis, 22 
Gartner's tonometer, 173 
Gastralgia, 62, 253 
Gastrectasia, 234 
Gastric atony, 255 

atrophy, 254 

cancer, 269 
etiology, 269 
morbid anatomy, 269 
symptoms, 270 
stomach-contents in, 271 
differential diagnosis, 271 

contents, examination of, 237 

crises, 272 

erosions, 268 

hyperesthesia, 253 

neuroses, 247 

spasm, 252 

stenosis, congenital, 273 

syphilis, 273 

tuberculosis, 273 

ulcer, 262 



Gastric ulcer, definition, 262 
etiology, 262 
varieties, 263 
pathology, 263 
diagnosis, 264 
hemorrhage in, 265 
colic, 64 

with adhesions, 268 
Gastritis, acute, 261 

glandularis acuta, 261 
chronic, 261 
Gastrodiaphane, 233 
Gastrointestinal disturbance in an- 
aemia, 400 
tract in impaired compensation, 

201 
tract in pneumonia, 142 
Gastroptosis, 236, 256, 260 
Gastrosuccorrhcea, 245 
Gastroxynsis, nervous, 246 
Gelsemium, poisoning, 638 
Gendrin's type of paralysis, 542 
General anasarca, n 

diffuse tuberculosis, 153 
paralysis of the insane, 587 
paresis, 587 
expression of, 4 
Generalized sweating, 10 
Geographic tongue, 23 
Gerhardt's sign, 97 
German measles, 462 

temperature in, 56 
Gibraltar fever, 454 
Gilles de la Tourette disease, 614 
Gin-drinker's liver, 301 
Girdle pains, 596 

sensation, 72, 526 
Glanders, 487 

Glands, diseases of bronchial, 163 
Glenard's disease, 2S7 
Glioma, 580 
Globus hystericus, 74 
Glosso-pharvngeal nerve, lesions of, 

566 
Glottic breathing, 102 
Glottis, edema of, 122 
Gluteal reflex, 529 
Glycosuria, 333, 372 
definition, 37a 
causes, 37a 

symptoms, 374 

coma in, 374 
urine in, 375 
variations in urine, 375 

prognosis, 375 



66o 



INDEX. 



Glycuronic acid in urine, 338 
Glucose in urine, 333 
Gnawing pain, 62 
Goitre, exophthalmic, 419 
Goll, column of, 518, 521 
Gonococcus in urine, 349 

examination for, 349 
Gout, 509 

etiology, 509 

symptoms, 509 

irregular gout, 510 

hereditary tendency, 47 
Gouty kidney, 361 
Gower's disease, 592 

haemoglobinometer, 385 
Graefe's sign, 420 
Grand mal, 610 
Granular casts, 347 

kidney, 361 
Graves' disease, 419 
Gray hepatization, 138 
Growth, new of heart, 220 
Growths of pleura, malignant, 166 
Guaiacum test for blood, 332 
Guinea worm disease, 504 
Gummata of liver, 304 
Gums, alterations of in disease, 23 
Gurgling rales, 105 
Gyromele, Tiirck's, 235 

Hematology, 376 
Haematoporphyrin, 319 
Habit spasm, 614 
Habits, influence of, in vertigo, 75 
and environment, influence of, 

39 

influence of, 38 

in relation to occupation, 42 
Hacking cough, no 
Haines' test, 334 
Hair in syphilis, 479 
Hallucinations, 535 
Hamburg, cholera in, 442 
Hands, alterations in disease, 25 
Handshake in disease, 25 
Hanot's cirrhosis, 301, 304 
Hard pulse, 171 
Harsh respiration, 10 1 
Hay fever, 118 
Hay craft's test for bile, 333 
Hayem's solution, 389 
Haygarth's nodosities, 510 
Head, appearance of, in disease, 16 

in cranio-tabes, 16 

in hydrocephalus, 1 7 



Head, in leontiasis ossea, 17 

in osteitis deformans, 17 

in rickets, 16 

tenderness of, 73 
Headache, feigned, 629 

in pneumonia, 142 

significance of, 66 

symptoms of, 68 

varieties, 67 
Heart, 167 

aneurism of, 220 

palpation of, 179 

percussion of, 179, 180 

auscultation of, 180 

areas of relative dulness, 83 

auscultation areas, 183 

boundaries, 83 

congenital defects, 199 

dilatation of, 191 

examination of, 177 

foreign bodies in, 220 

hypertrophy of, 191 

motility of, 83 

new growth of, 220 

pang, 222 

rupture of, 220 

transposition of, 221 
Heart-disease, color of skin in, 6 

congenital, 198 

decubitus in, 34 

feigned, 629 
Heartburn, 252 
Heart murmurs, 183 

causal factors, 189 

differentiation of, 190, 191 

in aortic regurgitation, 195 

in aortic stenosis, 192 

in mitral regurgitation, 191 

in mitral stenosis, 194 

organic, 186 
varieties, 186 
production, 186, 187 
deductions, 187, 188 

in pulmonary regurgitation, 198 

in pulmonary stenosis, 193 

in tricuspid regurgitation, 193 

in tricuspid stenosis, 197 

rare, 198 

relative frequency of, 190 
Heart muscle, degeneration of, 218 
Heart sounds, 181 

first sound, 181 
second sound, 181 

changes in, 182 

reduplication of, 182 



INDEX. 



661 



Heart sounds, significance of, 181 
Heart-valves, situation of, 84 
Heat and nitric acid test, 327 
Heat exhaustion, 488 
Heberden's nodes, 25, 510 
Hectic, 52 

Hedin-D aland, hematocrit, 391 
Height, significance of, $6 
Height and weight, relation of, 37 
Heintz's method (uric acid), 322 
Heller's test, 327 

for blood, 332 
Haematemesis, 250 
Hematocrit, Hedin-Daland, 391 
Hematogenous jaundice, 8 
Hematology, 376 
Hematoma auris, 19 
Hematomyelia, 569 
Hematorrhacis, 569 
Hematuria, 331 
Hemic murmurs, 184 
Hemocytometer, Oliver's, 391 

Thoma-Zeiss, 388 
Hemoglobin, 381 

estimation by specific gravity, 

3% 

tests for, 382 
Hemoglobinometer, 385 

Dare's, 383 

Gower's, 385 

Oliver's, 385 

Tallqvist's, 382 

von Fleischl's, 383 
Hemoglobinuria, 331 
Hemophilia, 412 

definition, 412 

etiology, 412 

symptoms, 412 

prognosis, 413 

hereditary tendency, 47 
Hemianesthesia, 537 
Hemicrania, 67 
Hemianopsia, 554 
Hemiatrophy, facial, 17, 609 
Hemiopia, 554 
I Hemiplegia, 583 

gait of, 35 
Hemorrhage, cerebral, 581 

concealed, 80 

feigned, 639 

in gastric ulcer, 265 

subcutaneous, 14 
1 Hemorrhagic infarct, 161 

pachymeningitis, 568 

pancreatitis, acute, 205 

43 



Hemorrhagic purpura, 412 

smallpox, 469 
Hemorrhea, 23 
Hemorrhoids, 278 
Henoch's purpura, 411 
Hepatic cirrhosis, 301 

coloration of skin in, 7 
Hepatic hyperemia, 299 
Hepatitis, acute, 297 

chronic, 301 
Hepatization, gray, 138 

red, 138 
Hepatogenous jaundice, 8 
Hereditary ataxia, 592 

cerebellar, 593 
Hereditary spastic paraplegia, 594 
Hereditary spastic spinal paralysis, 

.594 
Heredity, alteratives in, 46 

apoplexy and, 47 

cancer and, 47 

diabetes and, 47 

gout and, 47 

hemophilia and, 47 

influence of, 46 

nervous system in, 47 

special conditions affecting, 48 

syphilis and, 48 

tuberculosis and, 47 
Hernia, feigned, 630 
Herpes of lips, 20 
Herpes zoster, 607 

pain in, 70 
Heterochylia, 247 
Hiccough, significance of, 79 
High fever, 50 

significance of, 51 
High pressure, 173 
Hill's dictum, 478 
Hippocratic countenance, 442 

succussion, 106 
Hippus, 553 

History of present ailment, 40 
Hoarse cough, in 
Hoarseness, 29 

in paralyses, 546 
Hobby, influence of a, 45 
Hodgkin's disease, 40S 
( definition, 408 

historic note, 408 

etiology. 409 

pathology, 409 

varieties, 409 

acute, 409 
symptoms, 4C9 



66 2 



INDEX. 



Hodgkin's disease, acute, differential 
diagnosis, 410 
unusual symptoms, 410 
prognosis, 410 
Hollow cough, no 
Home, influence of, 46 
" Horrors," 490 
Hour-glass contraction, 260 
Housemaid's knee, 42 
Hutchinsonian syndrome, 480 

teeth, 24 
Hyaline casts, 345 
Hydatids, 300, 498 

pulmonary, 166 
Hydrocele, feigned, 630 
Hydrocephalus, congenital, 578 

feigned, 630 

head in, 17 
Hydrochinon in urine, 318 
Hydrochloric acid, quantitative tests 
for, 241 

test for, 239 
Hydrocyanic acid poisoning, 638 
Hydronephrosis, 369 
Hydrophobia, 485 
Hydrothorax, 138 
Hymenolepsis nana, 497 
Hyperacidity, 266 
Hyperacusis, 565 
Hyperalgesia, 539 
Hyperchlorhydria, 245 
Hyperesthesia, 539 

gastric, 253^ 
Hyperidrosis, significance of, 10 
Hyperkinesis, 252 
Hypermotility, 215 
Hyperpyrexia, 50 
Hvperresonance, 96 
Hyperthyrea, 419 
Hypertrophic cirrhosis, 301, 304 

rhinitis, 116 
Hypertrophy of heart, 191 

pseudo-muscular, 602 
Hypaesthesia, 537 
Hypobromite solution, Rice's, 321 
Hypochondria, 618 
Hypochlorhydria, 246 
Hypochylia, 255 
Hypodermic marks, 16, 41 
Hypcdermic needle, use of in pleural 

effusions, 135 
Hypogastric neuralgia, 283 
Hypoglossal nerve, lesions of, 568 
Hypoleucocytosis, 377, 393 
Hysteria, ^ 6l 5 



Hysteria, etiology, 615 

symptoms, 616 

diagnosis, 617 

prognosis, 618 

cough in, 109 

feigned, 630 

headache in, 68 

traumatic, 620 
Hysterical haemiplegia, 585 

joints, 28 

peritonitis, 292 

spastic paraplegia, 595 

Icterus, 8 

gravis, 9 

neonatorum, 9 
Icteric sputum, in 
Idiocy, amaurotic family, 595 
Idleness, influence of, 45 
Ileo-colitis, 280 

acute, 281 
Illness, influence of previous, 49 
Illumination, oblique, 559 
Illusions, 534 
Image, 559 
Immediate auscultation, 99 

percussion, 91 
Immobility of spine, 27 
Immunity, 49, 447 
Impaction, fecal, 65 
Impaired compensation, 200, 201 
Impulsive tic, 614 
Inability to stand, 36 

to walk, 36 
Incompensation, complete, 199, 202 
Incontinence of urine, feigned, 630 
Increase of weight, significance of, 37 
Incubation period of influenza, 439 
Incurvation of nails, 25 
Indican, 316, 317 
India-rubber ball sound, 106 
Indirect diagnosis, 2 

motor tract, 517 

sensory tract, 518 
Indol, 317' 

test for, 317 
Indoxyl, 316 

tests for, 316, 317 
Indurative edema in syphilis, 478 
Inequality of pupils, 552 
Infantile convulsions, 33 

meningitis, 577 

scurvy, 430 
Infantilism, 426 

pancreatic, 426 



INDEX. 



663 



Infarct, pulmonary, 161 

Infection, influence of exposure to, 

.4 8 
Infectious arthritis, 508 

diseases, 427 

in certain occupations, 44 - 
Inferior maxillary nerve, lesions of, 

562 
Inflammation of appendix, 288 

of bronchi, 123 

of heart, 217 

of intestines, 279 

of liver, 297 

of lungs, 138 

of kidneys, 356 

of nerves, 605 

of stomach, 261 

of spinal cord, 595 

of stomach, technic, 236 
Influenza, 438 

historic note, 439 

etiology, 439 

symptoms, 439 

prognosis, 441 
Inherited predisposition, 46 
Inhibition, 514 
Injury, simulated, 623 
Inoscopy, 397 
Insanity, feigned, 630 
Insolation, 488 
Insomnia, 75, 534 
Inspection, general, 3 
Inspiratory whoop, in 
Insufficiencies, cardiac, relative, 202 
Insular sclerosis, 570 
Intensity, 93 

Intentional tremor, 30, 31 
Intercostal neuralgia, 70 
Interlobular pleurisy, 136 
Intermittent claudication, 36 

fever, 52 

joint effusions, 609 
Internal anthrax, 484 

capsule, lesions of, 541 

meningeal hematoma, 568 
interstitial emphysema, 125 

pneumonia, [64 
Intestinal conditions, diagnosis by 
inflation and rectal injec- 
tions, 66 

embolism, 287 

Inflammation of, .'70 

acute intestinal indigestion, 270 

acute fermentative diarrhea, »8o 

cholera infantum, 2S0 



Intestinal conditions, dysentery, 280 

membranous enteritis, 283 

neurasthenia, 284 

neuroses, 283 

obstruction, acute, 291 

obstruction, pain in acute, 64 

obstruction, chronic, 284 

occlusion, 65 

paralysis, pain in, 65 

strictures, 65 

thrombosis, 287 

tumors, 65 
Intestines, diseases of, 274 

paralysis of, 284 

syphilis of, 287 

tuberculosis of, 287 
Intoxications, 488 
Intussusception, 65, 285 
Inverse temperature, 51 
Iodine, influence of, 43 
Iodophilia, 394 
Iris, disturbances of, 558 
Iron in urine, 324 
Irregular gout, 510 
Irregularities in outline of liver, 230 
Irregularity of the pulse, 170 
Irritative lesions affecting motor 

areas of cortex, 526 
Itching, 73 

Jacksonian epilepsy, 540, 611 
Jaffe-Stokvis test, 316, 317 
Japanese river fever, 456 
Jaw jerk, 527 

Jaws, alterations in disease, 25 
Jaundice, 7, 9, 631 

acute febrile, 308 

catarrhal, 305 

chronic catarrhal, 305 

malignant, 308 
Jeffe's test, 319 
Jerk, muscle, 526, 527 
Jerky respiration, ;S 
Joint effusions, intermittent, 609 
Joints, alterations in disease, 27 

Charcot's, 591 

tenderness of, 73 
Jolly's myasthenic reaction, 604 
Jossuet's method of inoscopy, 397 

K.ila a/.ar, 457 
etiology, 45 7 

symptoms, 457 

termination, .157 

ELernig's sign, 575 



i 



I 



66 4 



INDEX. 



Kidney, acute congestion of, 356 

acute inflammation of 356 
etiology, 356 
morbid anatomy, 357 
symptoms, 357 
urinary findings, 358 
prognosis, 359 

amyloid, 365 

characteristic features, 232 

chronic diffuse inflammation 
with exudation, 364 
etiology, 365 
symptoms, 365 
urinary findings, 365 

chronic interstitial inflamma- 
tion, 361 
morbid anatomy, 361 
etiology, 362 
symptoms, 362 
circulatory signs, 362 
fundus signs, 363 
respiratory signs, 363 
urinary findings, 363 
prognosis, 364 

chronic parenchymatous inflam- 
mation, 359 
etiology, 359 
morbid anatomy, 359 
symptoms, 360 
urinary findings, 360 
prognosis, 361 

chronic passive congestion of, 

355 

morbid anatomy, 355 

symptoms, 355 
diseases of, 310 

color of skin in, 6 

facies of acute, 6 

facies of chronic, 8 
dropsy of, 369 
inefficiency, 354 
inflammation of pelvis of, 367 
movable and floating, 365 

degrees of displacement, 366 

etiology, 366 

symptoms, 366 
physical examination of, 231 
of pregnancy, 355 
situation of, 225 
small white, 361 

morbid anatomy, 361 

symptoms, 361 

urinary findings, 361 
tuberculosis of, 368 

varieties, 368 



Kidney, tuberculosis of, diagnosis' 
368 
tumors, 369 
Kitasato's bacillus, 443 
Klebs-Loffler bacillus, 463 
Knee jerk, 528 
Koplik's spots, 20, 458 
Kyphosis, 27 

La cocotte, 438 
La follette, 438 
La grippe, 438 
Lab ferment, 240 
Lacquer poisoning, 494 
Lactic acid, test for, 239 
Lactose in urine, 337 
Laennec's cirrhosis, 301, 302 
Landry's paralysis, 599 
Large pulse, 171 

tongue, 23 

Laryngeal nerves, lesions of, 566 

Laryngismus stridulus, 122 

Laryngitis, acute, 121, 122 

subacute, 121 

chronic, 122 

syphilitic, 123 

tuberculous, 123 
Larynx, diseases of, 115, 121 

in paralyses, 544 

tumors of, 123 
Lateral curvature of spine, 27 

sclerosis, gait of, 35 
primary, 593 
secondary, 593 
Lathy rism, 493 
Laws of fremitus, 90 
Lead acetate poisoning, 639 

colic, 64, 491 

influence of lead, 44 

palsy, 491 
Lead-poisoning, chronic, 490 

symptomatology, 491 
Leathery edema, 11 
Leg, alterations in disease, 26 
Legal's test for acetone, 338 
Leontine facies in leprosy, 483 
Leontiasis ossea, 424 

head in, 17 
Leprosy, 482 

mode of conveyance, 484 

development, 482 

varieties, 482 

differential diagnosis, 482 
Leptothrix buccalis, 252 
Lesions affecting speech, 536 



INDEX. 



66 5 



Lesions of extraocular muscles, test 
for, 561 ; 

associated with visual disturb- 
ance, 555 
Lethargy, 58 
Leucocytes, 385 

classification, 386 

abnormal forms, 386 
Leucocyte count, 390 
Leucocytosis, 377, 392 

physiological, 392 

pathological, 393 
Leucopenia, 377, 393 
Leukemia, 404 

pathogenesis, 404 

varieties, 404 

lymphatic, 406 

spleno-medullary, 404 
Leukoplakia buccalis, 23 
Levulose in urine, 337 
Lieben's test for acetone, 338 
Light percussion, 92 

response, 553 
Limping, 35 

feigned, 631 
Lipase, test for, 240 
Lips, 20 

acute swellings of, 20 

epithelioma of, 20 

herpes of, 20 

pallor and cyanosis of, 20 

syphilis of, 20 
Litten's diaphragm phenomenon, 

88 
Little's disease, 594 
Liver, acute yellow atrophy of, 308 

amyloid degeneration of, 305 

cirrhosis of, 301 
varieties, 301 
etiology, 301 
morbid anatomy, 301 
symptoms, 302 
prognosis, 303 
differential diagnosis, 303 

congenital anomalies of, 296 

diseases of, 296 

dulness, 82, 95 

echinococcus cysts of, 300 

gin-drinkers', 301 

nyperaemia of, 29c) 

inflammation of, 207 

irregularities in outline, 830 
parasitic involvement o\, 300 

percussion outline of, • • 5 
physical examination of, 1 a8 



Liver, pyemic abscess of, 297 
symptoms, 297 
complications, 298 
differential diagnosis, 298 
prognosis, 299 

secondary carcinoma of, 299 

syphilis of, 304 

tumors of, 299 
Lobar pneumonia, 138 
Lobelia poisoning, 639 
Lobes of lungs, 82 
Lobular pneumonia, 144 
Local asphyxia, 608 
Localized edema, collateral, 12 

peritonitis, 292 

sweating, 10 
Localizing symptoms of cerebral 

hemorrhage, 584 
Lockjaw, 486 
Locomotor ataxia, 35, 590 

definition, 590 

etiology, 590 

morbid anatomy, 590 

symptoms, 590 

differential diagnosis, 592 

joints in, 28 
Lordosis, 27, 548 
Lost compensation, 200 
Louis, angle of, 80 
Low pressure, 173 
Lues venera, 475 
Lumbago, 71, 631 
Lumbo-abdominal neuralgia, 71 
Lumbar puncture, 575 
Lumpy-jaw, 487 
Lung, abscess, 161 

actinomycosis, 166 

aspergillomycosis, 166 

borders, 95, 96 

cirrhosis of, 164 

fever, 138 

gangrene of, 162 

hydatids of, 166 

infarct, 161 

inflammation of, 138 

syphilis, [65 
tumors of, 16a 
Lungs, Si , 82 
situation. Si 

Location, etc., 8a 
boundaries Si 
congestion oi. 149 

diseases o\ , 1 ;S 

in impaired compensation, 201 

lobes of, 8 ' 



666 



INDEX. 



Lupinosis, 493 

Lymph glands in syphilis, 479 

Lymphatic anaemia, 406 

symptoms, 406 

blood findings, 406 
Lymphatism, 416 

definition, 416 

historical note, 416 

etiology, 416 

symptoms, 416 
Lymphocytes, large, 386 

small, 386 
Lymphocytosis, 377, 392, 394 
Lysis, 56 
Lyssa, 485 
Lyssophobia, 485 v 

Macroscopy of stomach contents, 

239 
Malaria, 448 

definition, 448. 

historic note, 448 

mosquito in, 448, 449 

Plasmodium in, 450 

blood in, 450 

symptoms, 451 

classification, 452 

chronic, 452 

diagnosis, 452 

headache, 67 
Malarial cachexia, 452 
Malingerers, expression of, 4 
Malingering, 622 
Malignant adenitis, 443 

anthrax edema, 484 

growths of the pleura, 166 

jaundice, 308 

icterus, 9 

purpuric fever, 573 

pustule, 483, 484 

smallpox, 469 
Malta fever, 454 

definition, 454 

etiology, 454 

morbid anatomy, 455 

history, 455 

symptoms, 455 

differential diagnosis, 456 

prognosis, 456 
Mania a potu, 490 
Mania, 630 

Bell's, 55 
Manifestations of fever, 54 
Marble edema, 11 
Marechalt's test for bile ^^^ 



Marey's sphygmograph, 174 
Marie's disease, 421, 593 
Marks, hypodermic, 16 
Marsh miasm, 448 
Mast cells, 387 
Mastodynia, 70 

McBurney's point, 62, 225, 289 
McMonagle's manoeuvre, 289 
Meals, test, 238, 239 
Measles, 457 

definition, 457 
etiology, 457 

morbid anatomy, 458 

symptoms, 458 

complications, 459 

diagnosis, 459 

temperature in, 55 
Measurements, abdominal, 88 

chest, 88 
Meat poisoning, 493 
Mediastinal abscess, 164 
Mediastinitis, decubitus in, 34 
Mediate auscultation, 99 

percussion, 91 
Mediterranean fever, 454 
Medulla oblongata, lesions of, 543 
Megaloblasts, 387 
Megalocytes, 387 
Megastoma entericus, 494 
Melancholia, 630 

expression of, 4 
Melanaemia, 394 
Melanin, test for, 318 
Melano- sarcoma, coloration of skin 

in, 7 
Melanosis, arsenical, 7 
Malasicterus, 9 
Membranous croup, 123, 462 

diarrhoea, 283 

enteritis, 283 
Memory, defective, 534, 630 

loss of memory, 630 
Meniere's disease, 565 
Meningitis, 571 

morbid anatomy, 572 

varieties, 573 

acute tuberculosis, 576 

alcoholic, 577 

chronic, 578 

decubitus in, 34 

epidemic cerebro-spinal, 573 

infantile, 577 

secondary, 577 

septic, 577 

syphilitic, 576 



INDEX. 



667 



Mensuration in pleurisy, 134 
Mental obtuscness, 534 
Mental strain, influence of, 42 
Mercuric chloride, poisoning, 638 
Mercury, influence of, 44 
Mercurial stomatitis, 21 
Merycismus, 252 
Mesoblasts, 388 
Metallic cough, no 

tinkling, 106 
Meteorism, 283 

Methods, diagnostic in pulmonary 
and cardiac diseases, 84 

of examining sputum, 113, 114, 

fluoroscopic, 89 

Topfer's, 244 
Metric equivalents, table of, 642 
Microblasts, 388 
Microcytes, 387 
Micrococcus melitensis, 454 
Micromegally, 424 
Microscopic findings in stomach 

contents, 251 
Microscopy of sputum, 113, 114 

of urine, 339 
Micturition, 530 

frequency of, 312 
Migraine headache, 67 
Miliary fever, 456 

sclerosis, 570 

tuberculosis, 153 
Milk fever, 456 
Milky urine, 314 
Milk leg in typhoid, 430 
Mind blindness, 536, 537 

deafness, 537 
Mineral acids, poisoning, 635 
Mineral poisoning, influence of, 43 

tremor in, 31 
Miscarriages, significance of, 41 
Miscellaneous diseases of occupa- 
tion, 44 
Miscellaneous neuralgia, 70 
Misnamed ailments, 40 
Mitral regurgitation, 101 

stenosis, 194 
Motility of the heart, 83 
Moderate fever, 50 

percussion, 02 

Mode of onset of fevers, 56 

Modes of testing tremor, 30 

Moebius sign, .jjo 

Mohr's test for urinary chloride. 



Moist cough, no 

eye, significance of, 18 

rales, 104 

skin, significance of, 10 
Monoplegia, 539 
Morbid flushing, 74 
Morbilli, 457 
Morbus Addisonii, 414 

cceruleus, 198 

maculosus, 410 

Werlhoffi, 412 
Mortality of bubonic plague, 445 

of diphtheria, 465 

of influenza, 441 

of pneumonia, 144 

of scarlet fever, 000 

of typhoid fever, 438 

of tuberculosis, 154, 156 
Morton's foot, 70 
Mosquito in malaria, 449 

in yellow fever, 446 
Motility, disordered gastric, 255 
Motor aphasia, 29, 536 

lesions, 526 

nerves, 516 

nerves of eye, 560 

points of Erb, 532, 533 

power of stomach, test for, 241 

tracts, 514 
Mountain fever, 456 
Mouth, alterations in secretions of, 
21 

breathers, 20, 117, 119 

eruptions in, 21 

inflammation in, 21 

pigmentation of, 20 
Movable kidney, 365 
Movements, chest, 88 
Movement and pain, 62 
Moving gait, 35 
Mucopurulent sputum, itt 
Mucous click, 105 

colic, 283 
Multiple neuritis, 605 
causes, 606 
recurrent, 600 
diagnosis, 607 

sclerosis, 570 
Mumbling speech, 29 
Mumps, 450 

definition, 450 
etiology, 450 
morbid anatomy, \6o 
symptoms, 460 
complications, 460 



v 



M 



668 



INDEX. 



Murmur in aortic regurgitation, 195 

cardiorespiratory, 185 

crackling, 185 

Flint, 196 

in aortic stenosis, 192 

intensity of heart, 184 

in mitral regurgitation, 191 

in mitral stenosis, 194 

in pulmonary regurgitation, 198 

in pulmonary stenosis, 193 

in tricuspid regurgitation, 193 

in tricuspid stenosis, 197 

presystolic, 190 

systolic, 187, 188 
Murmurs, accidental, 185 

anaemic, 184, 400 

associated, 198 

heard before systole, 190 

heart, 183, 189 

hemic, 184 

organic heart, 186 

pleuropericardial, 185 

rare, 198 

relative frequency of, 190 

rhythm of heart, 189 

with diastole, 189 

with systole, 189 
Muscae volitantes, 556 
Muscle involvement in spinal paral- 
ysis, 546, 547> 548, 549 

sense, 537 
Muscles, diseases of, 604 

examination of, 531 
Muscular atrophies, differential di- 
agnosis of, 603 

dystrophies, 602 
etiology, 602 
classification, 602 

rheumatism, 71 

weakness in anaemia, 399 
Mushroom poisoning, 639 
Myasthenia gravis, 604 
Mydriasis, persistent, 552 
Myelaemia, 405 
Myelitis, 595 

acute transverse, 595 

compression, 595 

primary chronic, 598 
Myelocytes, 386 
Myocarditis, 217 
acute, 218 
chronic, 218 
symptoms, diagnosis, 218 

termination, 219 
Myoidema, 32 



Myosites, 604 

Myositis ossificans progressive, 604 

Myotonia, 36, 604 

Myxedema, 416 

definition, 416 

classification, 417 

etiology, 417 

symptoms in child, 417 

symptoms in adult, 418 

diagnosis, 418 

Nasal carcinoma, 118 

exostoses, 117 

headache, 68 

polypi, 118 

sarcoma, 118 

syphilis, 118 
Nausea, 248 
Neapolitan fever, 454 
Necrosing ethmoiditis, 117 
Negri bodies, 486 
Nephritis, color of skin in, 6 

with exudation, chronic diffuse, 

3 6 4 

acute, 356 

facies of acute, 6 

facies of chronic, 8 

chronic interstitial, 361 

chronic parenchymatous, 359 
Nerve, inflammation of, 71 
Nervosa, anorexia, 254 
Nervous dyspepsia, 253 

symptoms in typhoid, 433 

system, diseases of, 512 
in fever, condition of, 54 
in heredity, 47 
Neuralgia, 68 

significance of, 68 

varieties of, 69 
Neurasthenia, 618 

symptoms, 618 

special senses in, 619 

diagnosis, 620 

intestinal, 248 

traumatic, 620 

tremor in, 31 
Neurasthenic headache, 68 
Neuritis, 71, 490, 605 

multiple, 605 

optic, 557 

sciatic, 70 

toxic, 605 
Neurone theory, 512 
Neuroses, gastric, 247 . 

intestinal, 283 



INDEX. 



669 



Neuroses, traumatic, of Oppenheim, 

620 
Neurotic cough, 109 
Newton's ring, 389 
Night-sweats, 157 
Nitric acid contact test, 327 
Nitric acid test for bile, ^^^ 
Nitrogen, total, in urine, 319 
Nodding spasm, 31 
Nodes, Heberden's, 511 
Nodosities, Haygarth's, 510 
Noma, 22 
Normal acidity, 245 

breath sounds, 98, 100 

eruption of teeth, 24 

percussion notes, 93, 94 

temperature, 50 
Normoblasts, 387 
Nose, 18 

diseases of, 115, 116 

foreign bodies in, 119 
Nose-bleed in typhoid, 431 
Nose-rubbing, significance of, 73 
Nucleated red blood cells, 387 
Nuclei of cranial nerves, 552 
Nucleo-albumin, 325 

test for. 325 
Numbness, 74 
Nummular sputum, 112 
Nystagmus, 18, 42 

Obermayer's reagent, 317 
Obesity. 36, 426 
Objective signs of disease, 3 
Oblique illumination, 557 
Obstruction, pain in acute intestinal, 

64 
Obstructive jaundice, 8 
Occupation cramps, 31 

and habits, 42 

influence of, 41 

involving excessive heat, 44 

stigmata, 44 
Ochronosis, 19 
Ocular re Ilexes 552 

palsies, significance of, 18 
Odor of breath, 20 

in diabetes, 20 

in disease of alimentary tract, ao 

in disease of respiratory tract, 20 

in poisoning, 20 

in ursemia, 20 

( >dor of sputum, 113 

of urine, 3] | 
Odors as aids to diagnosis, 5 



Oedema of glottis, 122 

Oidium albicans, 21 

Olfactory sense, test for alterations 

in > 55 1 
Oligemia, 377 
Oligochromemia, 377 
Oligocythemia, 377 
Oliguria, 312 
Oliver's haemocytometer, 391 

haemoglobinometer, 385 
Operative myxedema, 418 
Ophthalmoplegia, progressive, 602 
Ophthalmoscopy, 557 

indirect, 559 

direct, 559 
Opisthorcis felineus, 495 
Opisthorchis sinensis, 495 
Opium habitue, ( olor of, 7 

influence of, 40 

poisoning, 639 
Oppression, sensation of, 74 
Optic atrophy, 590 
Optic nerve, 554 

neurones, 554 

course, 554 

lesions, 554, 555 

disturbances of, 552 

neuritis, 557, 596 

thalamus, 541 
Organic heart murmurs, 186 

reflexes, 530 
Origin of motor nerves of eye, 560 
Orthopnea, 78 
Osier's disease, 408 
Osteitis deformans, 424 

head in, 17 
Outline of liver, irregularities in, 230 
Outward signs of disease, 3 
Overweight, significance, 38 
Oxalates in urine, 324 
Oxalic acid, poisoning, 639 
Oxy acids in urine, 318 
Oxybutyric acid in urine, 33S 
Oxyuris vermicularis, 500 



Paget's diseases, 494, 104 

Pain, feigned, 633 

general consideration of, 71 

in various diseases, character 

ami location of, 6a, 63 
in locomotor ataxia, 591 

significance of, 61, 7- 
varieties, 61 6a 

Various localities of, ) a 



670 



INDEX. 



Painless inflammation, 62 
Palate reflex, 527 

soft, changes in, 25 
Pallor, significance of, 6 

of lips, 20 
Palpation, 89 

pressure, 91 
Palsy, Bell's, 564 

lead, 491 

shaking, 615 
Pancreas, diseases of, 295 

carcinoma of, 296 
Pancreatic abscess, 296 

calculi, 278, 296 

cysts, 296 

infantilism, 426 
Pancreatitis, acute hemorrhagic, 295 
etiology, 295 
symptoms, 295 
diagnosis, 295 
prognosis, 296 

acute suppurative, 296 

chronic, 296 

gangrenous, 296 
Pandemic chorea, 614 
Paradoxical contraction, 530 
Paragonimus Westermani, 496 
Paragraphia, 536 
Paralysis, 583 

of adult, spastic, 593 

agitans, 615 
symptoms, 615 
diagnosis, 615 
gait of, 35 
tremor in, 30 

asthenic bulbar, 

brachial plexus, 549 

decubitus in, 34 

facial, 564 

feigned, 632 

Landry's 599 

of extraocular muscles, 560, 561 

of the insane, 587 

of pharynx, 121 

of the intestines, 284 

pain in intestinal, 65 

periodic transient, 607 

pressure, 607 

progressive bulbar, 600, 601 

segmental, 543 

in stupor, 60 
Paralytic dementia, 587 

etiology, 587 

morbid anatomy, 587 

symptoms, 587, 588 



Paralytic dementia, variations, 589 

differential diagnosis, 589 

cyto-diagnosis, 589 
Paramyoclonus multiplex, 32 
Paranoia, 630 
Paraphrasia, 29, 536 
Paraplegia, ataxic, 592 
Parasites, vegetable, in stomach 

contents, 252 
Parasitic involvement of liver, 300 

stomatitis, 21 
Parasyphilitic affections, 589, 590 
Paratyphoid fever, 429 
Parenthetic neurones, 513 
Paresis, 587 

tremor in, 31 
Paresthesia, 73, 537 
Paretic dementia, 630 
Parkinson's disease, 615 
Parosmia, 551 
Parotitis, 459 
Paroxysmal cough, no 

dyspnoea, 77 

pain, 62 
Parry's disease, 419 
Passive congestion of kidney, chronic, 

355 • 

of lungs, 149 
Passive tremor, 30 
Patch, smoker's, 23 
Pathognomonic symptoms, defini- 
tion of, 2 
Patient, attitude in abdominal ex- 
aminations, 226 
attitude during auscultation, 100 
attitude of, for chest examina- 
tion, 85 
position of, during percussion, 

93 

preparation of, for chest exam- 
ination, 85 
Patellar reflex, 528 
Pachymeningitis, 568 

hemorrhagic, 568 

external, 569 
Pectoriloquy, 103 
Pediculus capitis, 506 

corporis, 506 

pubis, 507 
Pellagra, 493 . 
Pentose in urine, 337 
Pepsin, test for, 240 
Pepsinogen, test for, 240 
Percussion, abnormal notes, 96, 97 

methods of performing, 91 






INDEX. 



671 



Percussion notes, normal, 93', 94 

notes in disease, 96 

sounds, 93 

varieties of, 92 
Perfect compensation, 200 
Perforating ulcer of foot, 591 
Pericarditis, 215 

etiology, 215 

morbid anatomy, 215 

symptoms, 215 

chronic adhesive, 216 

diagnosis, 217 
Perihepatitis, chronic, 301, 302 
Peliosis rheumatica, 411 
Peroneal type of muscular atrophy, 

602 
Perinuclear basophilia, 395 
Periodic transient paralysis, 607 
Peristaltic unrest, 252, 283 
Peristalsis, visible, 228 
Peritoneum, cancer of, 295 
Peritonitis, acute, 291 
varieties, 291 
symptoms, 292 
differential diagnosis, 293 

chronic, 293 
varieties, 294 
differential diagnosis, 294, 295 

decubitus in, 34 

feigned) 632 
Pernicious anaemia, 398 

malaria, 452 
Persistent aortic isthmus, 199 

dyspnoea, 77 

ductus arteriosus, 199 
Pertussis, 473 

Perversions of sensations, 73 
Pest, 443 
Pestes major, 444 

minor, 445 
Petechial fever, 573 
Petit mal, 611 
Poisoning, acute, 635 

chronic, 488 
Pharynx, diseases of, 115, 119 

in paralyses, 544 
Pharyngitis, acute, 119 

chronic, 119 

syphilitic, 120 
Phlegmonous gastritis, 261 
Phenomena, auscultatory, 98 

of fever, 54 

miscellaneous venous, 177 
phenomenon, Friedreich, 07 

Litten's diaphragm, 88 



Phenomenon, Wintrick's, 97 
Phenolphthalein, 244 
Phlebosclerosis, 221 
Phosphates in urine, 323 

in urinary sediment, 339 
Phosphaturia, 323 
Phosphorus, influence of, 44 

poisoning, 640 
Phthisis florida, 154, 164 

pulmonary, 151 
Physical examination of abdomen, 
227 

of kidneys, 231 

of liver, 228 

of spleen, 230 

of the stomach, 233 
Physical resemblance, 48 
Physician, attitude of, during chest 

examination, 85 
Physiognomy of yellow fever, 447 
Pigeon-breast, 86, 425 
Pigmentation of buccal cavity, 20 
Pigmented tongue, 23 
Piles, 278 

"Pill-rolling" tremor, 30 
Pitch, 93 

Plague, bubonic, 443 
Plantar neuralgia, 70 

reflex, 530 
Plasmodium malarias, 450 
Plethora, 377 

Pleura, malignant growths of, 166 
Pleurisies, chronic, 136 
Pleurisy, 131 

definition, 131 

anatomy, 131 

etiology, 132 

symptoms, 132 

physical signs, 132, 133, 134 

course, 136 

termination, 136 

chylous, 166 

decubitus in, 34 

diaphragmatic, decubitus in, 34 

interlobular, 136 

with elTusion, 133 
Pleuritic adhesions, 135 
Pleural cough, no 
Pleurodynia, 71 
Plexinu ter, 91 
Plexor, 01 

Plugs, Dittrich's, 1 ia 
Pneumatosis, 252 
Pneumonia, catarrhal, 144 

lobar, 138 



A 



672 

Pneumonia, lobar, etiology, 138 
morbid anatomy, 138 
predisposing'J: actors, 139 
varieties, 140 
regions^selected, 140 
symptoms, 140^ 
blood in, 141 
urine in, 141 
physiognomy, 142 
physical signs, 142 
diagnosis, 143 
termination, 144 
prognosis, 144 

chronic interstitial, 164 
causes, 164 
morbid anatomy, 164 
symptoms, 165 

lobular, 144 
Pneumonic plague, 444 
Pneumonitis, 138 
Pneumothorax, 136 

definition, 136 

etiology, 136 

morbid anatomy, 137 

symptoms, 137 

physical signs, 137 

cardinal signs, 137 

course and termination, 138 

tympanitic note in, 97 
Pleuropericardial murmurs, 185 
Poached-egg belly, 13, 303 
Poggi, corpuscles of, 387 
PoiMlocytes, 387 
Point, McBurney's, 289 
Poisoning, acute, 635 

mineral acids, 635 

aconite, 635 

arsenic, 636 

atropin, 636 

cantharides, 636 

carbolic acid, 637 

caustic alkalies, 637 

chloral hydrate, 637 

cocaine, 637 

colchicum, 637 

croton oil, 637 

castor oil, 638 

corrosive sublimate, 638 

formaldehyde, 638 

gelsemium, 638 

hydrocyanic acid, 638 

lead acetate, 639 

lobelia, 639 

mushroom, 639 

oxalic acid, 639 



INDEX. 






Poisoning, opium, 639 

phosphorus, 640 

potassium nitrate, 640 

potassium chlorate, 640 

stramonium, 640 

strychnine, 640 

tartar emetic, 641 

tartaric acid, 641 

its effect on tongue, 23 

odor of breath in, 20 

pupils in, 58 
Polarimeter, 336 
Poliomyelitis, anterior acuta, 599 
etiology, 599 
morbid anatomy, 599 
symptomatology, 600 
prognosis, 600 

anterior chronica, 600 
Polycythemia, 377, 408 

cryptogenetic, 408 

cyanotic, 408 
Polymorphonuclear neutrophiles, 386 
Polyneuritis, acute febrile, 605 
Polypi, nasal, 118 
Polyuria, 312 
Pons, lesions of, 542 
Position assumed in bed in disease. 
33 

of patient during percussion,'. 

Positive penetrating venous pulse. 

177 
Post-nasal adenoids, 119 
Post-stenotic gastric motor insuffici- 
ency, 258 _ 
Post-tussive suction, 106 
Posterior spinal sclerosis, 590 
Postero-lateral sclerosis, 592 
Posture in pseudo-muscular hyper- 
trophy, 603 
Potassium chlorate, poisoning, 640 

ferrocyanide test, 329 

nitrate, poisoning, 640 

indoxyl sulphate, 317 
Pox, 475 
Pernicious anaemia, 403 

etiology, 403 

pathogenesis, 403 

symptoms, 403 

blood-findings, 403 
Preagonal leucocytosis, 392 
Precautions in weighing, 37 
Precordial pulsations, 177, 178 

bulging, 179 
Predisposition, inherited, 46 



INDEX. 



673 



Pregnancy, kidney of, 355 
Preliminary remarks on case-taking 

and diagnosis, 1 
Preparation of patient for chest ex- 
amination, 85 

of vaccine, 471 
Pressure, blood, 172, 173 

palpation, 91 

paralysis, 607 

stethoscope, influence of, 99 
Presystolic murmur, 190 

thrill, 179 
Previous illness, influence of, 49 
Primary chronic myelitis, 598 

combined sclerosis, 592 

lateral sclerosis, 593 

syphilis, 476 
Progressive bulbar paralysis, 600, 
601 

muscular atrophy, 31, 600 
Proliferative peritonitis, 294 
Prolonged expiration, 10 1 
Prostatitis, acute, 370 

chronic, 370 
Prostatic plugs, 348 
Pus in urine, 331 
Pseudo-asthma, 209 
Pseudo-crisis, 57 
Pseudo-Corrigan pulse, 400 
Pseudo-hydrophobia, 485 
Pseudo-hypertrophic paralysis, gait 

of, 36 
Pseudo-leukemia, 408 
Pseudo-muscular hypertrophy, 602 
Psoriasis, buccal, 23 
Psorospermiasis, 504 
Psychic derangements, 534 
Psychoses, epileptic, 611 
Ptomaine poisoning, 492 
Ptosis, 561 
Puerile breathing, 101 

respiration, 101 
Puffiness of eyelids, 17 
Pulex irritans, 507 
Pulmonary actinomycosis, 166, 488 

abscess, 161 
symptoms, 162 
prognosis, 162 

apoplexy, t6i 

areas, auscultatory, 100 

cirrhosis, 164 

embolism, 161 

gangrene, 162 
symptoms, 162 
prognosis, 162 



Pulmonary hydatids, 166 

hypertrophic osteoarthropathy, 

424 
infarct, 161 
inflammation, 138 
phthisis, 151 
regurgitation, 198 
resonance, 93 
stenosis, 193 
syphilis, 165 
tuberculosis, 151 
tumors, 162 

symptoms, 162 

prognosis, 162 
Pulsation, anaemic, 210 
expansile, 206, 207 
in region of manubrium, 178, 

179 
precordial, 177, 178 
Pulse, arterial, 167 

technic, 167 

important points, 167 

precautions, 167 

frequency, 168 

increased, 169 

decreased, 169 

irregularity, 170 

arrhythmia, 170 

varieties, 171 
capillary, 196 
Corrigan, 196 
in fever, 55 

frequency, normal, 168 
renal, 55 
in stupor, 60 

and temperature ratio in ty- 
phoid, 432 
positive penetrating venous, 177 
venous, 176 
water-hammer, 196 
wave, 170 
Pulsus alternans, 170 
bigeminus, 170 
trigeminus, 170 
paradoxus, 170 
celer, 171 
tardus, 171 
vacuus, 171 
Puncture, lumbar, 575 
Pupil, alterations in disease, 58, 55a 

in stupor from various causes, 
58 

Punlv's test for urinary chlorides. 

3 '3 

Purging iu cholera, 44a 



674 



INDEX. 



Purin basis, 322 
Purpura, 14, 410 

complicating, 411 

arthritic, 411 

simple, 411 

peliosis rheumatica, 411 

Henoch's, 411 

hemorrhagica, 412 
Purulent sputums, 111 
Pus in urinary sediment, 342 
Putrid sore throat, 462 
Pyelitis, 367 

definition, 367 

etiology, 367 

symptoms, 367 
Pyelonephritis, 367 

symptoms, 368 
Pyemia, 481 

Pyemic abscess of the liver, 297 
Pyrocatechin, 318 
Pyroplasmosis hominis, 505 
Pyrosis, 252 

Qualitative tests for albumin, 327 
tests for stomach contents, 239 
tests for sugar, ^33, 334, 335 

Quality of percussion sounds, 93 

Quantitative tests for albumin, 330 
_ tests for sugar, 336, 337 

Quinsy, 121 

Rabies, 485 

Race, influence of, 39 

Rachitis, 424 

decubitus in, 34 
Rachitic rosary, 87, 425 
Radiating pain, 62 
Railroad brain, 620 

spine, 620 
Rales, varieties, 104 

characteristics, 104 
Range, temperature, 50 
Rapid aging, significance of, 38 
Ray-fungus, 487 
Raynaud's disease, 608 
Reaction to accommodation, 553 

end, 243 

of degeneration, 531 

of sputum, in 

of urine, 314 
Readings, temperature. 50 
Record of residence, importance of ,45 
Rectal spasm, 283 
Red blood-cell, 385 

nucleated, 387 



Red hepatization, 138 
Reduplication of heart sounds, 182 
Reed, work in yellow fever, 446 
Reeling gait, 35 
Referred pain, 61 
Reflex arc, 515 

cough, no 

vomiting, 248 
Reflexes, 513, 527 
Regurgitation, aortic, 195 

mitral, 191 

pulmonary, 198 

tricuspid, 193 
Relapsing fever, 452 

definition, 452 

etiology, 453 

morbid anatomy, 453 

symptoms, 453 
Relation of height and weight, 37 

of pathologic changes in nervous 
system to symptomatology, 

525 
of pulse and respiration in fever, 

. 55 
Relative dulness of heart, 83 

insufficiencies, cardiac, 202 
Remittent fever, 52 
Renal colic, 63 

edema, n 

inefficiency, 354 

methylene blue test, 354 

inflammation, 356 

pulse, 55 

tuberculosis, 368 

tumors, 369 
Rennin, test for, 240 
Resemblance, influence of, 48 
Residence, influence of, 38, 45 
Resistance, percussion, 93 
Resolution, 139 

delayed, 140 
Resonance, increased, 96 

diminished, 97 

echoing, 104 

pulmonary, 93 

skodaic, 96 

vocal, increased, 103 
decreased, 103 

vocal of heightened pitch, 103 
Resonant rales, 106 
Respiratory movements, palpation 
of, 89 

rhythm, variations in, 78 
Respiration, Biot's 78 

cog-wheel, 101 



INDEX. 



675 



Respiration in fever, 55 
jerky, 78 
stertorous, 77 
Retention of urine, feigned, 632 
Retinoscopy, 558 
Retraction of apex, 87 

systolic, 178 
Retropharyngeal abscess, 120 
Regional divisions of abdomen, 224 

chest, 80 
Rheumatic purpura, 411 
Rheumatism, acute, 507 
etiology, 507 
symptoms, 507 
differential diagnosis, 508 
infectious arthritis, 508 
feigned, 632 
muscular, 71 
subacute, 509 
Rhinitis, atrophic, 117 
acute, 116 
chronic, 116 
hypertrophic, 116 
Rhizopoda, 494 
Rhythm, variations in respiratory, 

78 
Rice's hypobromite solution, 321 
Rickets, 424 

etiology, 425 
symptoms, 425 
prognosis, 425 
chest in, 86 
head in, 16 
Riegel test dinner, 239 
Rhine's test, 565 
Risus sardonicus, 486 
Robert's test, 329 
Rock fever, 454 
Romberg's sign, 591 
Rosary, rachitis, 87 
Rose-spots in typhoid, 431, 432 
Rosen bach's test, 318 
Roseola, syphilitic, 477 
Rossbach's disease, 245, 246 
" Rosy chlorotics," 6 
Rotch's sign, 216 
Rotheln, 462 

definition, 462 
symptoms, 462 
temperature in, 56 
Rubner's test for Lactose, 337 
Rubella, temperature in, 55 
Rubeola, temperature in, 56 
Running pulse, 171 
Rupture of the heart, 220 



Saccharometer, Einhorn's, 335 
Saddle nose, 19 
Sahli's haemoglobinometer, 385 
Salivation, 21 
Saikowski's test, 319 
Saltatory spasm, 6x5 
Sarcina ventriculi, 252 
Sarcoma, cerebral, 580 
heart, 220 
lung, 162 
nasal, 118 
pleura, 162 
Sarcoptes scabiei, 506 
Scabies, 506 

Scales, thermometer, 643 
Scanning speech, 535 
Scapular reflex, 528 
Scarlatina, 460 

temperature in, 59 
Scarlet fever, 460 
definition, 460 
etiology, 460 
prevalence, 460 
mortality, 460 
symptoms, 460 
complications, 461 
diagnosis, 462 
temperature in, 56 
Scars, 15 

on tongue, 23 
Schistosomum, haematobium, 404 
Schmidt's method of examining 

feces, 275 
Schonlein's disease, 411 
Sciatica, 70 

feigned, 632 
Sciatic neuralgia, 70 
Sclerosis, amyotrophic lateral, 600, 
601 
feigned, 633 
miliary, 570 
multiple, 570 
postero-lateral, 592 
primary combined, 592 
primary lateral, 593 
secondary lateral, 593 
Scorbutus, 413 
etiology, 413 
symptoms, 413 • 
decubitus in, 34 
Scotomata, 556 

Scrivener's palsy, 31 

Scurvy, 413 

feigned, 633 

Seat of pain, significance of, 61 



676 



INDEX. 



t 



Secondary anaemia, 398, 402 

broncho-pneumonia, 148 

meningitis, 577 

spastic paralysis, 593 

syphilis, 476 
Sediment in sputum, method of con- 
centrating, 114 

in urine, 339 
inorganic, 339 
organized, 342 
Sedentary life, influence of, 41 
Segmental paralyses, 543 

symptoms, 546, 547, 548, 549 
Segments of spinal cord, 545 
Seliwanoff's test for levulose, 331 
Semilunar space, Traube's, 82 
Sensation, perversions of, 73 
Sensory aphasia, 29, 536 

centres and pathways, 525 

disturbances, significance of , 538 

functions, investigations of, 537 

tract, direct, 517 
indirect, 517 
functions of, 519 
Septal abscess, 117 

deviations, 117 

haematoma, 117 
Septic arthritis, joints in, 28 

meningitis, 577 
Septicaemia, 481. 
Septicaemic plague, 444 
Serous effusions, 12 

sputum, 112 
Serum, albumin in urine, 325 
Sex, influence of, 38, 39 
Sexual abuse, expression of, 4 
Shaking palsy, 615 
Shape of head in disease, 16 
Shifting dulness, 82 
Shingles, 607 
Ship fever, 453 
Shock, significance of, 79 
Shortness of breath, 76 
Sibilant rales, 104 
Sick headache, 67 
Siderosis, 165 
Sign, Biermer's, 98 

Gerhardt's, 97 

Kernig's, 575 

Romberg's, 591 

Rotch's, 216 
Signs, outward, of disease, 3 

fluoroscopic, 109 

of life, 734 
Silent cerebral tracts, 539 



Simple anaemia, 398 

catarrh of mouth, 2 1 

purpura, 411 
Simulated injury, 623 
Sinking sensation, 74 
Siriasis, 488 

Sites of thoracic aneurism, 205 
Situs viscerum inversus, 221 
Skatol carbonic acid, 317 
Skatol, 317 

test for, 318 
Skin, condition of, in fever, 54 

crepitation of, 14 

significance of condition of, 10 
Skodaic resonance, 96 
Sleep, disturbances of, 534 

feigned, 628 

inability to, 75 
Sleeping-sickness, 505 
Small pulse, 171 
Smallpox, 56, 466 

definition, 466 

historic note, 466 

etiology, 467 

morbid anatomy, 467 

contagiousness, 467 

varieties, 467 

symptoms, 467 

eruption, 468 

complications, 469 

prognosis, 469 

diagnosis, 470 
Small red kidney, 361 

white kidney, 361 
Smear preparation, blood, 379 
Smoker's cough, no 

patch, 23 
Snap diagnosis, definition of, 2 
Sneezing, 19 

Social state, influence of, 38, 41 
Soft palate, alterations in, 25 
Solids, urinary, 316 
Sonorous rales, 104 
Sound, coin, 104 
Sounds, abnormal chest, 106 

breath, 98, 100, 101, 102 

heart, 181 

percussion, 93 
Spade hand of acromegaly, 25 
Spasm, esophageal, 310 

gastric, 252 

rectal, 283 
Spasms, 31 

Spasmodic asthma, 128 
Spasmus nutans, 31 



INDEX. 



677 



Spastic cerebral paraplegia, 594 
diplegia, 594 
gait, 35 

paraplegia, 593 

hereditary, 594 

hysterical, 595 

of infants, 594 

Specific gravity of urine, 315 

Speech, alterations in disease, 28 

disturbance of, 534 

changes in rhythm, 535 
central disturbances, 535 
lesions, 536 
examination, 536 
varieties of, 29 
Special conditions affecting heredity, 

4 8 
Spectroscopic test for urobilin, 318 

Spermatozoa in urinary sediment, 343 

Sphygmogram, 173, 174 

analysis of, 174, 175 
Sphygmograph, 173, 174 

Marey's, 174 

tracings, 175 
Sphygmomanometer, Riva-Rocci, 

172 
Spiegler's test, 329 
Spinal accessory nerve, lesions of, 

567 

cord, diseases of, 526, 568 
segments of, 545 

deformities, 27 

nerves, involvement of, 550 

paralysis, Erb's, 594 
hereditary spastic, 594 

sclerosis, posterior, 590 
Spine, immobility of, 27 

tumors and swellings of, 27 
Spirals, Curschmann's, 112 
Spirochaeta Obermeieri, 453 

pallida, 475 
Spleen, enlargement of, 231 

in typhoid, 432 

outline of, 225 

physical examination of, 230 
Spleno-medullary, 404 

etiology, 404 

symptoms, 404 

blood-findings, 405 
Splenic anaemia, 404 

Splil nails, 26 

Spondylitis rhyzomelique, 27 
Spotted fever, 453, 57 3 
Spots, Koplik's, 20, 458 
Spritz gerausch, 234 

44 



Sputum, significance, 111 

characteristics, in 

alterations, 1 1 1 

in tuberculosis, 153, 155, 156 
Staccato speech, 535 
Stained preparation of blood, exam- 
ination of, 380 
Staining solutions, 380 

of blood, technic of, 381 
Standard test-meals, 238, 239 
Starch in stomach contents, 240 
Station, 33 

Statistics of aneurism, 205 
Status lymphaticus, 416 
Stegomyia fasciata, 446 
Stelwag's sign, 420 
Stenosis, aortic, 192 

mitral, 194 

pulmonary, 193 

tricuspid, 197 
Step-ladder temperature, 432 
Steppage gait, 35 
Sterno-cleido-mastoid in paralysis, 

546 
Stertorous respiration, 77 
Stethoscope, 99 

Stethoscopic pressure, influence of, 99 
Sthenic fevers, 55 
Stokes-Adams syndrome, 169 
Stokes-von Huchard condition, 183 
Stomach, atony of, 257, 258 

bilocular, 260 

carcinoma, 269 

congenital stenosis of, 273 

crises, 272 

chronic dilatation, 257 

cough, no 

dilated, 256 

disorders, differential diagnosis, 
266 

erosions, 268 

general considerations, 233 
physical examination, 233 

fluoroscopy, 233 

hour-glass contraction, 260 

inflammation of, 261 

inflation, 235 

post stenotic motor insuffici- 
ency, 258 

syphilis of, 273 

tests for motor power of, 24] 

transillumination, 233 
tuberculosis of, 

ulcer of, 202 

ulcer with adhesions, 26S 



678 



INDEX. 



Stomach-contents in gastric carci- 
noma, 271 

withdrawal of, 237 

examination, 237, 238 

microscopic appearances, 239 

normal constituents, 239, 240, 
241, 243 

abnormalities, 244, 245, 246, 
247 
Stomach-tube, use, 236 

contraindications, 236 

technic, 237 
Stomatitis, 21 

aphthous, 21 

fetid, 22 

follicular, 21 

gangrenous, 22 

mercurial, 21 

parasitic, 21 

ulcerative, 22 

varieties of, 21 
Stones, urinary, 371 
Stools, character of, 274 
Strabismus, 561 
Stramonium poisoning, 640 
Strangulation, pain in, 64 
Strauss' method, 317 
Strawberry tongue, 22, 460 
Streptothrix actinomyces, 487 
Strictures, esophageal, 309 
Stridor, 77, 104 
"Stroke," 587 
Strong percussion, 92 
Stiongyloides intestinalis, 504 
Strychnine poisoning, 640 
Stupor, 58 

St. Vitus's dance, 612 
Subacute endocarditis, 214 

rheumatism, 509 
Subcrepitant rale, 105 
Subcutaneous emphysema, 14, 125 

hemorrhages, 14 
Sub-febrile temperature, 50 
Subjective dyspnoea, 78 

weakness, 74 
Subnormal temperature, 52 
Suffocative anerina, 462 
Sugar in urine, 333, 372 
Sulphates in urine, 324 
Sunstroke, 488 

symptoms, 488 

differential diagnosis, 488 
Superficial cardiac area, 82 
Supermotility, 252 
Supinator jerk, 527 



Suppressed breathing, 101 

cough, no 
Supramaxillary nerve, lesions of, 562 
Suppurative tonsillitis, 121 
Sweat, changes in quality, 10 

changes in quantity, 10 

critical, 56 
Sweating, alterations in, 10 

excessive, 10 

sickness, 456 
Swellings of spine, 27 
Sydenham's chorea, 612 
Syllabic speech, 29, 535 
Symmetrical gangrene, 608 
Sympathetic nervous system, lesions 

of, 568 
Symptoms, analysis of common, 49 

of jaundice, 9 

objective, 3 

subjective, 49 
Syncope, 74, 634 
Syphilis, 475 

mode of conveyance, 475 

modifying influences, 475 

three stages, 476 

hereditary, 480 

hereditaria tarda, 480 

comment, 480 

cerebral, 579 

coloration of skin in, 7 

expression of, 4 

hereditary tendency, 48 

in adults, expression of, 5 

intestinal, 287 

nasal, 118 

of lips, 20 

of the stomach, 273 

pulmonary, 165 
Syphilitic cirrhosis, 301, 304 

dactylitis, 25 

laryngitis, 123 

meningitis, 576 

pharyngitis, 120 

spinal paralysis, Erb's, 594 
Syringomyelia, 595 

joints in, 28 
Systole, 186 

murmurs with, 189 
Systolic bruit, 208 

murmur, 187, 188 

retraction, 178 

Tabes dorsalis, 590 

gait of, 35 
Table of metric equivalents, 642 



I 






INDEX. 



679 



Tachycardia, 169 
Tactile sense, 537 
Taenia echinococcus, 498 

mode of infection, 498 
distribution, 499 
symptoms, 499 
mediocanellata, 496 
saginata, 496 
solium, 497 
Tallqvist's haemoglobinometer 382 
Tapeworms, 496 
Tartar emetic poisoning, 641 
Tartaric acid poisoning, 641 
Taste, disturbances of, 563 
Tea, influence of, 40 
Technic of abdominal examinations, 
226 
of auscultation, 100 
of blood-counting, 387 
for determination of blood pres- 
sure, 172, 173 
for examining blood, 378 
of examination of nose, pharynx, 

and larynx, 115, 116 
of palpation, 90 
of percussion, 91 
of introducing stomach-tube, 

237 

of X-ray examination of chest, 
106, 107, 108, 109 
Teeth, changes in disease, 24 

Hutchinsonian, 24 

normal eruption of, 24 
Teeth-grinding, 25 
Teichmann's disease, 245, 246 

test, 251 
Temperatures, abnormal, 52 

subnormal 52 

in anaemia, 399 

method of taking, 49 

range, 50 

record in typhoid, 432 

in stuporous conditions, 60 
Tenderness, feigned, 631 

significance of, 61, 73 
Tendon reflexes, 528 
Termination of broncho-pneumonia, 
148 

of fever, 56 

of thoracic aneurism, 205 
Terms, blind, 46 

used in neurology, 522 
Tertiary syphilis, 479 
Test for arrtic acid, 239 

for acetone, ^S 



Test for albumoses, 325 

for butyric acid, 239 

for blood, Weber's, 250 

for diacetic acid, 338 

for hydrochloric acid, 239 

for hydrochloric acid, quantita 
tive, 241 

for indol, 317 

Jaffe-Stokvis, 316, 317 

Jeffe's, 319 

for lactic acid, 239 

for lactose, 337 

for levulose, 337 

for lipase, 240 

Mohr's, 323 

for melanin, 318 

for motor power of stomach, 
241 

for nucleo-albumin, 325 

for pentose, 337 

for pepsin, 240 

for pepsinogen, 240 

Purdy's, for urinary chlorides, 
323 

for pus in urine, 331 

for rennin, 240 

Rhine's, 565 

Rosenbach's, 318 

Salkowski's, 319 

for skatol, 318 

Strauss, 317 

Teichmann's, 251 

for urea, 321 

tor uric acid, 322 

for urinary chlorides, 322, 323 

for urobilin, 318 

for urocythrin, 318 
Test-diet, Schmidt's method, 276 
Test-meals, 238 
Tests for albumin, 326, 327, 328, 

3 2 9< 33° 
for albumin, quantitative, 330 
for albumin in sputum, 113 
for bile in urine, 333 
for blood in urine, 332 
for blood in vomit, 250 
electrical, 531 
for fats in urine, 314 
for haemoglobin, 38a 
for indican, 316, 31 7 
for indoxyl, 316, 31 7 

for mercurial stomatitis, 21 

for renal inefficiency, 354 
for sugar in urine, 333, 

335- 33° 



68o 



INDEX. 



Tests, for typhoid fever, 434 

for uric acid in urine, 322 
for urinary calculi, 371 
qualitative, for stomach con- 
tents, 239 
Tetanus, 486 

symptoms, 486 
diagnosis, 487 
prognosis, 487 
neonatorum, 486 
Tetany, 32 

Therapeutic diagnosis, 2 
Thermic fever, 53, 488 
Thermometer scales, 643 
Thoma-Zeiss haemocytometer, 388 
Thomas and Weber method, 240 
Thomsen's disease, 36, 604 
Thoracic aneurism, 204 
etiology, 204 

X-ray diagnosis, 204, 211, 212 
statistic, 205 
sites, 205 
termination, 205 
symptoms. 205, 208 
physical signs, 205 
pulse in, 206 
varieties, 209 
differential diagnosis, 210 
viscera, diseases of, 80, 81 
Thorax en bateau, 87 
Thread worms, 500 
Thready pulse, 171 
Thrill, presystolic, 179 
Thrombosis, cerebral, 571, 581, 586 
intestinal, 287 
of spinal cord, 590 
Tic convulsiv, 614 
douloureux, 69 
impulsiv, 614 
Tingling, 74 
Titubating gait, 35 
Tobacco, influence of, 40 
Toe reflex, 520 
Toisson's solution, 389 
Tongue, 22 

changes in appearance in dis- 
ease, 22 
in paralyses, 544 
strawberry, 460 
typhoid, 432 
Tonometer, Gartner's, 175 
Tonsils, diseases of, 121 
Tonsillitis, acute, 121 
chronic, 121 
suppurative, 121 



Topfer's method, 244 
Topical diagnosis, 539 
Topographical anatomy of chest, 80 
Torticollis, 71 

cervicalis, 31 
Touch, 537 
Toxaemic headache, 67 

jaundice, 8 

vomiting, 248 
Toxic neuritis, 606 
Toxicity of urines, relative, 354 
Tracheal tug, 207 

voice, 103 
Tracings of sphygmograph, normal, 

175 
abnormal, 175 
Tract involvement in disease, sig- 
nificance of, 522 
Tracts of spinal cord, functions of, 

519 
Transient edema, 1 1 

nodular swellings of legs, 26 
Transillumination of stomach, 233 
Transparency of urine, 314 
Transposition of heart, 221 
Traube's semilunar space, 82 

hysteria, 620 
Traumatic neurasthenia, 620 

neuroses of Oppenheim, 620 
Tremadota, 494 
Tremor, 30 

conditions associated with, 30 

of face, 30, 31 

modes of testing, 30 

of tongue, 23 

varieties, 30 
Triceps jerk, 528 
Trichina spiralis, 501 
Trichiniasis, 501 
Trichloracetic acid test, 329 
Trichocephalus dispar, 504 
Trichomonas vaginalis, 494 
Tricuspid regurgitation, 193 

stenosis, 197 
Trifacial nerve, lesions of, 562 

neuralgia, 69 
Trismus, 32 
Trichterbrust, 86, 87 
Trommer's test, ^^ 
Trophic changes in locomotor ataxia, 

59i 
Trousseau's sign, 32 
True croup, 123 

casts, 344 
Trypanosome fever, 505 



INDEX. 



681 



Tsetse fly, 505 

Tube, stomach, 236 

Tubercle bacilli in sputum, 100 

bacilli in urine, 353, 369 
Tuberculin as a diagnostic agent, 

158 
Tuberculosis, acute pneumonic, 154 

lobar form, 154 

pneumonic form, 154 
acute miliary, 153 

cause, 153 

morbid anatomy, 153 

symptoms, 153 

physical signs, 153, 154 

course, 154 
cerebral, 579 
chronic ulcerative, 155 

definition, 155 

pathologic anatomy, 155 

symptoms, 156 

physical signs, 159 

comment, 160 
hereditary tendency, 48 
intestinal, 287 
of bladder, 370 
pulmonary, 151 

definition, 151 

distribution, 151 

morbid anatomy, 151, 155 

spread of infection, 152 

etiology, 152 

site of lesions, 153 

onset, 153 

varieties, 153, 154, 155 

physical signs, 153, 154, 155, 

159 
symptoms, 153, 154, 156, 157 

renal, 368 

of stomach, 273 
Tuberculous arthritis, 509 

laryngitis, 123 

meningitis, acute, 576 

peritonitis, 294 
Tubular breathing, 102 
Tumors of bladder, 370 

of brain, 578 

of larynx, 123 

of the liver, 299 

of pharynx, 120 

of spine, 27 

pulmonary, 162 
Turck's gyromele, 235 
Turpentine, influence of, 44 
i\ mpany, 03, 96 
Typos, febrile, 52 



Typhoid fever, 427 

definition, 427 

etiology, 427 

varieties, 428 

pathologic anatomy, 429 

symptoms and diagnosis, 430 

diagnosis, 433 

differential diagnosis, 436 

prognosis, 438 
abortive, 432 
paratyphoid, 429 
tongue, 22, 432 
Typhus abdominalis, 427 
fever, 453 

definition, 453 

historic note, 453 

morbid anatomy, 453 

symptoms, 453 

prognosis, 453 

Ulcer, duodenal, 267, 286 

gastric, 262 

with adhesions, gastric, 268 
Ulcers in typhoid, 429 
Ulcerations of nails, 25 
Ulcerative endocarditis, 24 

stomatitis, 22 
Uncinariasis, 501 

symptoms, 502 
Unconsciousness, degree of, 59 

feigned, 633 
Under-weight, significance, 38 
Undulant fever, 454 
Unilateial flushing, significance of, 8 

pupillary contraction, 553 

spinal cord lesions, 526 
Uraemia, 350, 585 

nervous symptoms of, 350 

respiratory symptoms of, 351 

gastro-intestinal symptoms of, 

35i 

coma, 352 

odor of breath in, 20, 60 
Uranalvsis in stuporous conditions, 

60 
Urates in urinary sediment, ,; \0 
Urea in urine, 320 
Ureemic coma, 352 
Urethritis, ehronie, ;; 1 
Uric aeid in urinary sediment, 341 

in urine, 321 
Urinalysis, 310 
Urinary ehlorides, 322 

calculus, 37 1 

varieties, 371 



682 



INDEX. 



Urinary calculus, tests for, 371 
chemic examination, 371 

sediments, examination of, 339 
substances found in, 339, 340 
organized sediment, 342 

solids, 316 
Urine, acetone in, 388 

albumin in, 324 

ammonia in, 324 

Bence-Jones' proteid in, 326 

bile in, ^3 

blood in, 331 

casts in, 344 

changes in pneumonia, 141 

color of, 313 

diazo-reaction in, 349 

diacetic acid in, 338 

glucose in, 333 

Trommer's test, 333 
Fehling's test, ^^t, 
Haines' test, 334 
Allen's test, 334 
fermentation test, 335 
Whitney's quantitative test, 

33 6 

polariscopic test, 336 
glycuronic acid in, 338 
gonococcus in, 349 
in chronic cystitis, 370 
in acute cystitis, 369 
in acute nephritis, 358 
in amyloid kidney, 365 
in chronic diffuse nephritis with 

exudation, 365 
in chronic interstitial nephritis, 

in chronic parenchymatous 

nephritis, 360 
in small white kidney, 361 
in diabetes mellitus, 375 
iron in, 324 
lactose in, 337 
levulose in, 337 
maltose in, 7,7,8 
milky, 314 
normal amount, 312 
odor of, 314 
oxalates in, 324 
oxybutyric acid in, 338 
pentose in, 337 
phosphates in, 323, 324 
pus in, 331 
reaction of, 314 
solids in, 316 
specific gravity of, 315 



Urine, sugar in, ^33, 31* 

transparency of, 314 

tubercle bacilli in, 348 
Urines, relative toxicity of, 354 

phloridzin test for, 354 
Urinometer, 315 
Urobetin, 318 

chemical test, 318 

spectroscopic test, 318 
Urobilin icterus, 9 
Uroeythrin, test for, 318 
Urochroms, 319 
Urometer, Doremus, 321 
Uvula in paralyses, 543 

Vaccination, 470 

sequence of events in, 472 
Vaccine, preparation of, 471 
Vagabond's disease, 507 
Vagus, lesions of, 566 
Valves, situation of heart, 84 
Valvular areas, clinical. 84 
Varicella, 473 

etiology, 473 

symptoms, 473 

duration, 473 

complications, 473 

temperature in, 56 
Variola, 466 

temperature in, 56 

verrucosa, 469 
Varioloid, 469 

Vegetable parasites in stomach con- 
tents, 252 
Velum palaii in paralysis, 544 
Venereal diseases, feigned, 633 
Venous circulation, collateral, 14 

collapse, dicrotic, 176 

phenomena, miscellaneous, 177 

pulse, 176 

positive penetrating, 177 
Vertigo, feigned, 633 

significance of, 75 

varieties, 76 
Vesicular breathing, 10 1 
Vessels, examination of great, 177 

great, palpation of, 179 
percussion of, 179, 180 
auscultation of, 180 
Vicarious emphysema, 125 
Vincent's angina, 465 
Viscera, thoracic, 81 

diseases of thoracic, 80 
Visceral alterations in alcoholism, 
489 



INDEX. 



68 3 



Visible peristalsis, 228 
Visual acuity, 556 

amnesia, 29 

disturbances, significance of, 

555 

fields, 554 

field, test for, 556 

speech centre, 536 
Vocal cords in paralyses, 546 

fremitus, 90 

resonance, increased, 103 
decreased, 103 

resonance of heightened pitch, 
103 
Voice, alterations in disease, 28 

bronchial, 103 

tracheal, 103 
Volvulus, pain in, 64 
Vomiting, 248 

toxaemic, 248 

reflex, 248 

central, 248 

feigned, 633 
Vomitus, characteristics of, 249 
Von Fleischl's haemoglobinometer, 

3*3 
Von Leube test dinner, 239 
Von Recklinghausen's disease, 607 

Waddling gait, 36 
Wasting, 36 
Water brash, 252 

whistle sound, 106 
Water-hammer pulse, 196 
Waxy casts, 346 
Weakness, subjective, 74 
Weber's test for blood, 250 
Weight, significance of, 36 
Weight and height, relation of, 37 
Weil's disease, 308 
Wernicke's localizing reaction, 555 
Whip worm, 504 
White blood, 404 



Whitney's quantitative test for sugar, 

336 

Whooping-cough, 473 

definition, 473 

morbid anatomy, 474 

symptoms, 474 

diagnosis, 474 

complications, 474 

comment, 474 

mortality, 474 
Widal's agglutination test, 434 
Wintrich's phenomenon, 97 
Wiry pulse, 171 
Wool-sorter's disease, 483 
Word-blindness, 29 
Word-deafness, 29 
Working alae, 19 

Wright's staining method for blood, 
380 

stain, 397 
Wrist drop, 529, 550 
Wry-neck, 31 

feigned, 633 

X-ray in acromegaly, 422, 423 

examination of chest, 106, 107, 

108, 109 
in thoracic aneurism, 204, 211, 

212 

Yellow fever, 446 

definition, 446 

morbid anatomy, 447 

symptoms, 447 

physiognomy, 447 

prognosis, 448 

diagnosis, 448 

differential diagnosis, 44S 
Yellow jack, 446 

Zappcrt's chamber, 390 
Zona, 607 
Zoters, 607 






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